Abstract
This paper examines some examples of not well integrating evidence into healthcare decision-making within the Republic of Korea, a nation characterized by a rapidly evolving and financially strained healthcare system. The review introduces various conceptual frameworks of evidence-based practice, including Evidence-Based Medicine (EBM), Evidence-Based Public Health (EBPH), and Evidence-Based Health Policy (EBHP), alongside a nuanced typology of scientific (context-free and context-sensitive) and colloquial evidence. Through brief literature reviews, the paper identifies significant barriers and crucial facilitators to effective evidence utilization. These include deficiencies in research infrastructure, accessibility gaps, the influence of political and value-based considerations, and the pervasive challenge of "decision-based evidence making." The report concludes by proposing actionable recommendations aimed at strengthening the evidence ecosystem, fostering deliberative processes, enhancing Health Technology Assessment (HTA) integration, and cultivating a robust culture of evidence-informed policy-making in Korea.
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Keywords: Evidence-based medicine; Decision making; Health policy; Public health; Policy making
Introduction
Global landscape of evidence-based healthcare and policy
The global healthcare landscape is undergoing a profound transformation, marked by a decisive shift towards evidence-based practices (EBP). This paradigm represents a departure from traditional decision-making, which often relied on anecdotal experience, intuition, or opinion. The movement towards EBP is not merely a fleeting trend but a systemic response to mounting pressures within healthcare systems worldwide. Escalating healthcare expenditures, as observed in Korea [
1], coupled with the increasing complexity of modern medical science, necessitate more efficient and effective allocation of finite resources. EBP offers a structured framework to achieve this by minimizing the adoption of ineffective interventions and maximizing the impact of beneficial ones. This global movement provides a crucial benchmark against which the progress and challenges of evidence utilization within the Korean healthcare system can be critically assessed.
Evidence plays a pivotal role in ensuring the efficacy, safety, cost-effectiveness, and equitable distribution of healthcare interventions and policies. Robust, systematically generated evidence directly correlates with improved patient outcomes and contributes significantly to the long-term sustainability of health systems. The importance of evidence extends beyond mere clinical efficacy to encompass broader societal values, such as equity and justice, which are sometimes overlooked in frameworks driven purely by efficiency. For evidence to be truly impactful in policy, it must be multi-dimensional, integrating not only rigorous scientific data but also social determinants of health, population-level needs, ethical considerations, and patient values. The increasing emphasis on value-based appraisal methods in decision-making processes implicitly supports this broader, more holistic understanding of evidence [
2].
The Republic of Korea operates a universal National Health Insurance (NHI) system, which provides comprehensive coverage to 97% of its population. The remaining 3% of low-income individuals are covered by a tax-funded Medical Aid Program. Over recent decades, the Korean healthcare system has experienced rapid development, achieving impressive health outcomes. However, this growth has also presented inherent challenges, particularly concerning financial sustainability and equitable access. Understanding the structure, achievements, and ongoing challenges of this system is essential for contextualizing the subsequent analysis of evidence utilization in Korean healthcare decision-making.
Purpose and structure of the review
This review aims to examine the current state of evidence utilization in Korean healthcare decision-making. It seeks to identify prevailing challenges and emerging opportunities, ultimately proposing actionable recommendations for strengthening evidence-informed policy and practice. The paper is structured to first outline the conceptual frameworks of evidence, followed by an analysis of current practices through specific case studies. A comprehensive discussion of the identified barriers and facilitators to evidence utilization will then be presented, concluding with a set of targeted recommendations.
Conceptual Frameworks of Evidence in Healthcare Decision-Making
Defining evidence-based medicine, public health, and health policy
The concept of evidence-based practice has evolved across various domains within healthcare, leading to distinct yet interconnected definitions:
• Evidence-Based Medicine (EBM): EBM is fundamentally a systematic approach where healthcare professionals integrate the best available scientific evidence from clinical research with their individual clinical expertise and the patient's unique values and preferences. This integration is crucial for making informed decisions about the care of individual patients. It emphasizes a conscientious, explicit, and judicious use of current best evidence [
3].
• Evidence-Based Public Health (EBPH): EBPH extends the principles of EBM to the broader field of public health. It involves integrating science-based interventions with community preferences, practitioner expertise, and the specific characteristics, needs, values, and preferences of the target population [
4]. A key distinction is that randomized clinical trials (RCTs), while the gold standard in EBM, are not always directly applicable or feasible for investigating the complex, population-level problems inherent in public health [
5].
• Evidence-Based Health Policy (EBHP): EBHP represents a further evolution, focusing on the utilization of research findings to inform and support policy decisions at a systemic level. This often involves comprehensive research methods, including RCTs, but critically relies on good data, strong analytical skills, and robust political support for the integration of scientific information into policy formulation [
6].
This conceptual progression from EBM to EBPH and EBHP signifies a broadening understanding of "evidence" beyond the confines of clinical trials. EBM, rooted in clinical epidemiology and emphasizing RCTs [
7], forms a foundational concept. However, a strict application of EBM principles to public health or policy contexts proves challenging due to inherent differences in interventions, outcomes, and target populations [
5]. EBPH and EBHP explicitly recognize the need for diverse types of evidence, such as observational studies, quasi-experiment, and economic evaluations for public health [
8]. Furthermore, these broader frameworks acknowledge the significant influence of non-scientific factors, including political considerations and societal values [
9]. This conceptual evolution underscores the adaptive nature of evidence-based practices, which must be tailored to fit the specific nuances of different decision-making environments.
David Sackett's seminal definition of evidence-based medicine posits that effective practice requires the integration of three core components (Sackett's triad): the best available external clinical evidence from systematic research, individual clinical expertise, and patient values and preferences [
3]. This triad underscores that evidence alone is insufficient for optimal decision-making.
The explicit inclusion of "clinical expertise" and "patient values and preferences" within Sackett's framework is a crucial distinction. It directly refutes a simplistic interpretation of EBP as merely the mechanical application of research findings. This framework highlights the indispensable human element—the nuanced judgment of experienced clinicians and the unique circumstances and desires of patients—which introduces inherent subjectivity and context into the decision-making process, making it far more complex than a purely scientific exercise. This also establishes a conceptual link to the need for deliberative processes that can effectively integrate these diverse, often qualitative, perspectives alongside quantitative evidence.
Typology of evidence: scientific and colloquial evidence
Building on the work of Lomas et al. (2005), evidence in healthcare decision-making can be broadly categorized into scientific evidence and colloquial evidence [
10,
11].
Scientific Evidence:
Context-Free: This type of evidence is explicit, systematic, and replicable, typically generated through controlled experiments like randomized controlled trials (RCTs). It focuses on the general clinical potential, efficacy, and safety of interventions, aiming for universal applicability.
Context-Sensitive: While still systematic, this evidence is collected in ways more relevant to the specific real-world context in which a technology or intervention is to be used. It addresses aspects such as implementation feasibility, organizational capacity, economic implications (e.g., cost-effectiveness analyses), and ethical considerations within a particular setting.
Colloquial Evidence: This category encompasses information that is neither strictly scientific nor systematically collected, yet it is frequently the only available input for certain issues. It includes expert testimony, professional opinion, political judgment, values, practical considerations (such as resource availability), established habits or traditions, and the interests and views of specific groups (e.g., lobbyists, pressure groups). Policy-relevant documents not published in peer-reviewed journals also fall under this category [
12].
Ultimately, effective evidence-informed health policy making is best supported by a judicious combination of these three types of evidence, alongside other influencing factors. The explicit recognition and stated prevalence of colloquial evidence in policy decision-making is a critical observation. It highlights the inherent political and pragmatic realities that often influence, and sometimes supersede, purely scientific considerations. This is not necessarily a negative aspect if these diverse forms of evidence are integrated through transparent, structured, and deliberative processes. Lomas et al. make a crucial observation that "the use of colloquial evidence prevails among decision-makers" [
10]. This is an important point because it directly challenges the notion of policy as a purely rational, scientific exercise. It acknowledges that political judgment, the influence of various stakeholders, and practical resource constraints are always present and significantly impact decisions. The challenge, therefore, is not to eliminate colloquial evidence, which is often unavoidable and valuable for contextual understanding, but to integrate it systematically and transparently with scientific evidence [
13]. This also establishes a direct link to the concept of "decision-based evidence making," where evidence might be strategically employed to support a pre-determined policy direction, rather than genuinely inform or make the decision.
Table 1 provides a clear, structured overview of the different types of evidence discussed in these conceptual frameworks, making complex distinctions easily comprehensible. It visually demonstrates that the concept of "evidence" in health policy is not narrowly confined to highly controlled scientific studies like RCTs, but encompasses a much wider array of information, including qualitative data, experiential knowledge, and socio-political considerations. This broad understanding is crucial for appreciating the challenges and opportunities inherent in genuine evidence-informed decision-making. By clearly outlining the distinct roles and contributions of each evidence type, the table implicitly sets the stage for a deeper discussion on how these varied forms of evidence must be thoughtfully integrated and balanced for effective and legitimate policy-making, rather than relying on a singular, narrow definition of "best evidence."
The role of health technology assessment (hta) in evidence generation
Health Technology Assessment (HTA) serves as a vital policy tool designed to provide evidence-based information regarding health technologies. It achieves this by conducting comprehensive evaluations of their clinical efficacy, economic implications, social impact, ethical considerations, and legal ramifications. HTA plays a crucial role in reducing uncertainties in decision-making and facilitating systematic and transparent choices across various levels of the healthcare system, including national government, system-wide prioritization, and local budget allocation [
2].
HTA functions as a crucial bridge between diverse forms of evidence (both scientific and colloquial) and actual policy decisions, particularly concerning resource allocation and the adoption of new technologies. Its inherently multi-faceted evaluation framework implicitly acknowledges the complex nature of healthcare choices, which extend far beyond mere clinical effectiveness. The comprehensive scope of HTA, encompassing clinical, economic, social, ethical, and legal dimensions, signifies its design to integrate a wide array of evidence types. It moves beyond the narrow question of "what works" to address "what works, for whom, at what cost, and with what broader societal implications." This holistic approach positions HTA as a practical embodiment of evidence-informed decision-making, transcending a purely EBM focus to embrace a broader EBHP perspective. The identified barriers to ethical evaluation within HTA processes highlight specific areas where HTA's full potential in integrating diverse evidence and values might currently be under-realized [
2].
Current Landscape of Evidence Use in Korean Healthcare Policy
Healthcare expenditure trends and sustainability challenges in Korea
Korea's healthcare spending has demonstrated exceptionally rapid growth, recording the fastest pace among OECD countries. From 2010 to 2019, total health expenditure nearly doubled, with an average annual surge of 8%, significantly surpassing the OECD average annual increase of 3.6% [
14]. The ratio of health expenses to GDP in Korea rose from 6.5% in 2014 to 8% in 2019, a substantial 1.5 percentage point increase, starkly contrasting with the mere 0.1 percentage point increase in the OECD average during the same period [
15].
This upward trend is projected to continue, with health care spending expected to absorb 15% of GDP by 2065. This is primarily driven by a rapidly aging population, where the proportion of those aged 65 and older is projected to increase from 11% in 2010 to 42.5% by 2065, and increased healthcare utilization. While population aging contributes modestly to per-person spending growth, non-demographic factors such as economic growth, the expansion of National Health Insurance (NHI) coverage, and increased provision and utilization of health care services are identified as key drivers [
14].
Korea also exhibits a high proportion of out-of-pocket (OOP) payments, accounting for 29% of total health expenditures in 2021. This places it as the 5th highest among OECD countries and 11 percentage points above the OECD average. This significant reliance on OOP payments contributes substantially to final household consumption (6.1% in 2021, the highest among OECD countries) and leads to a high incidence of catastrophic health expenditures, particularly for low-income households (7.5% in 2016 faced OOP payments exceeding 40% of their income, compared to an OECD average of over 5%). The high OOP burden and existing gaps in NHI coverage have led to a significant increase in voluntary private health insurance, rising from 51% of the population in 2011 to 72% in 2021. In response, the Korean government launched an ambitious plan in 2017 to expand NHI coverage to include expensive services (e.g., MRI, ultrasound scans) and reduce co-payment rates, aiming to increase the public sector's share of healthcare spending to 70% by 2022 (it reached 62.3% in 2021, up from 58.9% in 2017) [
16].
Korea's uniquely rapid healthcare expenditure growth, coupled with a disproportionately high reliance on out-of-pocket payments and a lower public share of spending compared to OECD averages, indicates a healthcare system under significant and growing financial strain. This escalating financial pressure creates an urgent and compelling imperative for robust evidence-informed decision-making to ensure both the long-term sustainability and equitable access within the system. The prevalence of high out-of-pocket payments directly translates into significant barriers to access and exacerbates inequities, particularly for vulnerable populations, leading to "catastrophic health expenditures". This dire financial context elevates evidence-based resource allocation from a mere best practice to an absolute critical necessity for the system's long-term fiscal viability and adherence to principles of social justice. The governmental response, such as the expansion of NHI coverage, itself represents a major policy intervention that demands rigorous evidence to evaluate its effectiveness, efficiency, and overall sustainability [
16].
Medical school enrollment quota controversy
The controversy surrounding the medical school enrollment quota in South Korea provides a compelling illustration of the complexities of evidence utilization in high-stakes policy decisions. The government has advocated for a significant increase of 2,000 medical school seats, citing a projected shortage of 10,000 doctors by 2035, with an additional 5,000 needed to address regional imbalances [
17].
However, a critical aspect of this controversy is the disagreement between the government and the very researchers whose reports were used to justify this expansion. Prominent academics advocate for a more gradual increase, suggesting, for instance, 500-1,000 seats annually for five years. They also project a doctor surplus after 2045-2050, expressing regret that the government did not consider a more phased approach. This situation exemplifies the profound tension between scientific evidence, political judgment, and entrenched stakeholder interests in high-stakes health policy decisions. The disagreement extends beyond the raw data to encompass its interpretation, the assumptions underpinning future projections, and, crucially, the process by which decisions are ultimately reached. This strongly suggests the occurrence of "decision-based evidence making," where evidence is selectively utilized to legitimize or "support" a pre-determined policy outcome rather than genuinely inform or make the decision [
18].
The controversy has escalated into a “strong vs. strong” confrontation between the government and medical organizations. To resolve this impasse, the researchers have proposed parliamentary mediation or the formation of a social consultative body. They have also suggested the establishment of a specialized agency, similar to those in the United States and Japan, to provide objective evidence for doctor supply projections and other policy decisions, thereby fostering trust and depoliticizing contentious issues. The medical school quota debate serves as a compelling real-world illustration of how evidence becomes a battleground in a highly politicized policy environment. The government's assertion of a specific, large increase, despite the nuanced and more cautious recommendations from the very researchers whose work they cite, strongly indicates that the "evidence" is being used to support a policy that has already been decided. This highlights a fundamental breakdown in the evidence-informed decision-making process. The researchers' call for parliamentary mediation or an independent consultative body underscores the absence of a trusted, transparent, and deliberative mechanism capable of integrating diverse scientific interpretations, political imperatives, and stakeholder concerns in a legitimate and effective manner. This points to a systemic issue in governance and trust.
Management of non-covered medical services
The management of non-covered medical services by National Health Insurance Service in Korea presents another complex challenge for evidence-informed decision-making. These services are considered essential for providing patient choice, managing the efficiency of health insurance finances, and accommodating the rapid emergence of new medical technologies. Despite their perceived necessity, concerns persist regarding the weak evidence base for the efficacy or necessity of some non-covered medical procedures.
Recent amendments to the Medical Act (Article 45-2) now mandate healthcare institutions to report not only the prices but also the standards and detailed clinical records of non-covered services. This new requirement imposes a significant administrative burden on medical institutions, leading to concerns about excessive government control over pricing, quantity, and quality of these services. Critics argue that such government control over non-covered services fundamentally infringes upon patients' basic rights, asserting that these services are largely market-driven and subject to continuous evaluation by consumers through various platforms [
19].
The current health insurance system faces inherent dilemmas: providing the "best" medical services to all patients inevitably drives up costs; fully integrating all services into covered insurance benefits increases overall utilization; and accommodating diverse patient demands can lead to the proliferation of arbitrary non-covered services. Furthermore, structural issues within the Korean healthcare system, such as "unbalanced compensation for essential medical services" and "high civil/criminal burden" on providers, contribute to an "imbalance in personnel supply and demand" and a "concentration in private practice and non-covered services" [
20]. This suggests that economic incentives may be driving practice patterns away from evidence-based priorities in essential care.
The persistent challenges surrounding non-covered services reveal a fundamental tension within the Korean healthcare system: balancing market principles and patient autonomy with public health objectives and the demand for evidence-based value. The lack of robust evidence for certain services, combined with the administrative burdens and concerns about potential government overreach, highlights the profound difficulty of applying evidence-informed decision-making in areas where strong economic incentives and individual patient demand significantly influence practice patterns. The argument that non-covered services are "market-driven" and represent a "basic right" directly conflicts with the core EBP principle of ensuring efficacy, safety, and value for money. The administrative burden imposed by new regulations and the concerns about government control highlight the practical difficulties of implementing evidence-based regulations in a system with substantial private sector involvement. Critically, the link between "unbalanced compensation for essential medical services" and the concentration of providers towards non-covered services strongly suggests a systemic issue where economic incentives may be inadvertently driving clinical practice patterns away from evidence-based priorities in essential care, thereby creating a disincentive for both evidence generation and adherence in these lucrative, yet potentially unproven, areas.
Barriers and Facilitators to Evidence-Informed Decision-Making in Korea
Identified barriers to evidence utilization
The effective utilization of evidence in Korean healthcare decision-making is impeded by a multifaceted array of barriers:
• Lack of Research Evidence & Quality: A significant challenge is the insufficient research period and funding allocated to health policy studies, which often compromises the quality and reliability of existing research. There is also a notable dearth of timely, context-specific domestic research, making it challenging to apply findings directly to the unique Korean context [
9].
• Accessibility and Dissemination Gaps: Policymakers frequently report low accessibility to relevant research findings. Furthermore, there is a critical absence of dedicated organizations and effective programs specifically tasked with the systematic dissemination of research in Korea [
9].
• Translational Challenges: Difficulties exist in effectively translating the complex results of ethical analyses, often embedded within Health Technology Assessments, into practical, actionable knowledge that is readily useful for decision-makers [
2].
• Organizational and Resource Constraints: Decision-making bodies often suffer from limited ethical knowledge and expertise among their staff, coupled with insufficient time and financial resources to engage deeply with evidence and conduct thorough appraisals [
2].
• Methodological Complexity: Within Health Technology Assessment (HTA), the scarcity, heterogeneity, and inherent complexity of ethical analysis methods pose significant hurdles to their consistent and widespread application [
2].
• Policy-Research Disconnect: A critical criticism of evidence-based policy in Korea is that research evidence is frequently used to rationalize or legitimize specific policies that have already been decided, rather than genuinely informing the decision-making process from the outset [
9]. This phenomenon, often termed "decision-based evidence making," creates a fundamental gap between policy needs and research output, where international evidence might be generalizable but relevant domestic research is conspicuously lacking [
21].
• Value and Equity Concerns: There is an observed overemphasis on efficiency within the framework of research evidence, which makes it challenging to adequately reflect and integrate crucial societal values such as equity and justice into policy decisions [
9].
• Generalizability Issues: Research, particularly randomized controlled trials (RCTs), may not always be directly relevant for all treatment situations or sufficiently generalizable to diverse patient populations or individuals with complex multi-morbidities, limiting their direct applicability in real-world clinical and policy settings [
22].
• Lag in Application: A significant time lag often exists between the completion of RCTs, the publication of their results, and the proper, widespread application of these findings in practice [
22].
• Confirmation Bias: Practitioners and policymakers lacking sufficient skills in seeking and critically appraising evidence are prone to confirmation bias, selectively interpreting evidence that supports their pre-existing beliefs or experiences [
23].
The identified barriers collectively point to a systemic issue where the supply of relevant, high-quality evidence is insufficient, its translation and accessibility are poor, and the demand for it is often distorted by political and value-based considerations. This complex interplay creates a fertile ground for "decision-based evidence making" and severely limits the true impact and integrity of evidence-informed decision-making in Korean healthcare. The confluence of various barriers creates a deeply entrenched and complex web of challenges. It is not merely a quantitative lack of evidence, but fundamental deficiencies across the entire evidence ecosystem: from its production (e.g., inadequate funding, questionable quality), to its dissemination (e.g., poor accessibility, absence of dedicated intermediary bodies), to its translation (e.g., difficulties in converting complex research into policy-relevant knowledge), and ultimately, to its utilization (e.g., often for legitimization rather than genuine decision-shaping). The critique that evidence is presented as "value-neutral" but inherently emphasizes efficiency is particularly profound, revealing a fundamental philosophical tension within evidence-informed decision-making when applied to real-world policy contexts where values like equity and justice are equally, if not more, paramount.
Identified facilitators for evidence utilization
Despite the challenges, several factors can facilitate the integration of evidence into healthcare decision-making in Korea:
• Improved Research Support: A critical facilitator is the provision of sufficient research period and funding, alongside concerted efforts to enhance the overall quality and reliability of health policy research [
9].
• Enhanced Accessibility: Improving the accessibility of timely and context-specific domestic research findings to policymakers is crucial for their effective utilization [
9].
• Value-Based Appraisal Methods: The adoption and systematic usage of appraisal methods that explicitly integrate societal values into the evidence evaluation process can significantly facilitate utilization, ensuring that decisions reflect broader societal goals beyond mere efficiency [
2].
• Stakeholder and Public Engagement: Active involvement of diverse stakeholders and the broader public throughout the decision-making process is identified as a key facilitator. This recognizes their invaluable role in contributing "colloquial evidence" (e.g., lived experiences, community preferences) and thereby enhancing the legitimacy and public acceptance of policies [
2].
• Practice Guidelines & Ethical Expertise: The enhancement of existing practice guidelines and the cultivation of robust ethical expertise within decision-making bodies are important facilitators, providing clear frameworks for evidence application and ethical consideration [
2].
• Educational Interventions: Implementing targeted educational interventions and ongoing training programs for both practitioners and policymakers on evidence appraisal, critical thinking, and the nuances of different evidence types can significantly improve utilization and foster a more evidence-aware workforce [
2].
• Policymaker Demand: A strong, explicit demand for evidence from policymakers themselves is a potent facilitator, signaling institutional commitment to evidence-informed approaches and driving systemic change [
2].
• Deliberative Processes: The strategic utilization of deliberative processes that enable the negotiation of competing viewpoints, the integration of scientific opinion, and the thoughtful consideration of ethical and values-based dilemmas can significantly enhance evidence use and lead to more robust and accepted policy outcomes [
24,
25].
The identified facilitators highlight that strengthening evidence-informed decision-making necessitates a multi-pronged and integrated approach. This approach must simultaneously address both the supply side (ensuring the quality, relevance, and accessibility of evidence) and the demand side (cultivating policymaker engagement, capacity, and willingness to use evidence). Crucially, it emphasizes the pivotal role of deliberative processes in legitimately integrating diverse forms of evidence and often conflicting values. The consistent emphasis on "value-based appraisal methods" and "stakeholder and public engagement" is particularly noteworthy [
2]. This reinforces the understanding that effective evidence-informed decision-making is not solely about scientific rigor but also about achieving democratic legitimacy and social acceptance of policies. Deliberative processes are explicitly presented as a structured means to achieve this complex integration of diverse evidence and values, suggesting a necessary evolution from a purely technocratic view of evidence use to one that actively embraces complexity, pluralism, and public participation [
24].
A critical concept to address is "decision-based evidence making" (DBEM), which stands in stark contrast to genuine evidence-based decision-making. In DBEM, evidence is primarily gathered, or even modified, for the sole purpose of legitimizing a decision that has already been made [
18]. This phenomenon fundamentally transforms evidence from a tool for objective discovery and optimal choice into a mere rhetorical or political device, thereby undermining public trust and potentially leading to suboptimal, biased, or even harmful policy outcomes. This practice is particularly pertinent in the context of the Korean medical school enrollment quota controversy, where researchers' nuanced findings appear to have been selectively used to bolster a pre-determined government policy [
17].
Evidence can serve three distinct roles in decision-making: to
make a decision (an algorithmic, data-driven approach), to
inform a decision (combining hard facts with qualitative inputs), or to
support a decision (lending legitimacy to a pre-existing choice) [
18]. DBEM falls squarely into this "support" category, where evidence functions largely as a symbolic tool rather than a genuine shaper of outcomes. This practice can fundamentally subvert the ideal evidence-based process, particularly when subordinates or managers feel compelled to shape or present evidence in a way that aligns with the perceived expectations of higher-level leaders. The prevalence of DBEM in practice represents a significant and insidious threat to the integrity and effectiveness of true evidence-informed decision-making. It fundamentally transforms evidence from a tool for objective discovery and optimal choice into a mere rhetorical or political device, thereby undermining public trust and potentially leading to suboptimal, biased, or even harmful policy outcomes. The concept of DBEM provides a crucial understanding of why evidence might fail to be effectively utilized, even when it is readily available. This is not merely a technical problem of data availability or analytical capacity, but a deeply ingrained behavioral and political phenomenon within organizations and governments. Its direct connection to the Korean context, particularly the medical school quota debate where the government's specific numerical target seemed to precede and then selectively utilize research findings, strongly suggests DBEM at play. Recognizing and explicitly naming DBEM is essential for developing effective strategies that promote genuine evidence integration and critical appraisal, rather than merely facilitating the legitimization of pre-existing agendas. It shifts the focus from "what evidence is available" to "how is evidence
actually used and
why?"
Table 2 provides a structured, comprehensive overview of the multifaceted challenges and opportunities for evidence-informed decision-making in Korea, integrating both general EBP literature and specific findings from the Korean context. A clear and concise summary of the key challenges and their corresponding potential solutions serves as a direct, actionable input for the subsequent recommendations section, making the report highly practical for policymakers and researchers seeking to identify and prioritize areas for intervention to improve evidence utilization.
Recommendations for Strengthening Evidence Use in Korean Healthcare
Based on the analysis of conceptual frameworks, current practices, and identified barriers and facilitators, the following recommendations are proposed to strengthen evidence-informed decision-making in Korean healthcare:
Enhancing research infrastructure and accessibility
A robust evidence ecosystem fundamentally begins with the foundational elements of research production and accessibility. Without a consistent supply of high-quality, relevant, and easily discoverable evidence, any subsequent efforts to promote evidence-informed decision-making will be inherently limited and ultimately ineffective. Therefore, it is crucial to:
• Implement policies to significantly increase and stabilize research funding, ensuring sufficient duration for complex health policy studies [
9]. This will foster the generation of more comprehensive and rigorous evidence.
• Invest in initiatives to improve the quality, methodological rigor, and reliability of domestic health research. A particular focus should be placed on generating timely and context-specific evidence directly relevant to Korean healthcare challenges, addressing the current dearth of such studies [
9].
• Establish and adequately resource dedicated organizations or programs specifically tasked with the systematic dissemination of research findings. These entities should actively work to enhance the accessibility of evidence for policymakers and other decision-makers, bridging the existing dissemination gaps [
21].
Deliberative processes are not merely about gathering more evidence; they are fundamentally about creating a legitimate and transparent arena for negotiating conflicting values and interests that are inherent in complex health policy decisions. This is crucial for overcoming the "strong vs. strong" confrontations observed in Korea and for counteracting the pervasive tendency towards "decision-based evidence making." To achieve this, it is recommended to:
• Actively promote and institutionalize deliberative processes that explicitly integrate scientific evidence with diverse values, practical considerations, and the often-conflicting interests of various stakeholders [
24].
• Encourage and facilitate parliamentary mediation or the formation of independent, multi-stakeholder social consultative bodies to resolve contentious policy conflicts and build trust among disparate parties, as highlighted by the medical school enrollment quota controversy.
• Ensure genuine public and stakeholder engagement throughout the entire policy-making cycle. This recognizes their invaluable role in contributing "colloquial evidence" (e.g., lived experiences, community preferences) and thereby enhancing the legitimacy and public acceptance of policies [
2].
• Develop clear frameworks and structured methodologies for integrating diverse viewpoints and systematically negotiating ethical and values-based dilemmas, moving beyond a narrow, efficiency-driven focus [
9].
Strengthening HTA is vital for institutionalizing evidence-informed decision-making within the Korean healthcare system, as it provides a structured, multi-dimensional framework for comprehensively evaluating interventions and technologies. The empowerment of existing independent HTA bodies, particularly for contentious issues like workforce planning, could significantly depoliticize the evidence generation process and enhance public and professional trust in policy decisions. Specific recommendations include:
• Further integrate Health Technology Assessment (HTA) into all stages of health policy and reimbursement decisions. This integration should ensure that HTA's comprehensive evaluation encompasses not only clinical efficacy but also economic, social, ethical, and legal implications [
2].
• Actively address the identified barriers within HTA processes by simplifying complex methodologies, developing clear and practical good practice guidelines, and building internal capacity for robust analyses among HTA practitioners.
• Consider establishing a specialized, independent agency dedicated to long-term health workforce projections and other critical, contentious policy areas. This body should be insulated from short-term political pressures, drawing lessons from successful models in countries like the United States and Japan, to provide more objective and trusted evidence.
Promoting a culture of evidence-informed policy
Ultimately, the effective and sustained implementation of evidence-informed decision-making hinges on a fundamental cultural shift within the policymaking apparatus. This requires moving away from a reactive, politically expedient, or intuition-driven approach towards one that genuinely values, critically appraises, and systematically integrates evidence. This cultural transformation necessitates sustained commitment to capacity building, fostering transparency, and ensuring accountability across the system. Recommendations for this cultural shift include:
• Cultivate strong political will and foster an explicit demand for evidence from policymakers at all levels of government and healthcare administration [
2]. This top-down commitment is paramount for driving systemic change.
• Implement comprehensive educational interventions and ongoing training programs for policymakers, healthcare managers, and clinical leaders. These programs should focus on evidence appraisal, critical thinking skills, understanding the nuances of different evidence types, and recognizing the limitations of evidence [
2].
• Develop and disseminate clear, practical frameworks and guidelines for systematically integrating diverse types of evidence—including scientific (context-free and context-sensitive) and colloquial evidence—into the various stages of the decision-making process.
Conclusion
This review has underscored that the Republic of Korea faces both significant challenges and substantial opportunities in effectively integrating evidence into its healthcare decision-making processes. The analysis has highlighted the conceptual complexity of "evidence," encompassing various forms from Evidence-Based Medicine (EBM) to Evidence-Based Public Health (EBPH) and Evidence-Based Health Policy (EBHP), and the multi-level nature of decision-making within the healthcare system.
The case studies of the medical school enrollment quota controversy and the management of non-covered medical services have vividly illustrated the practical tensions between scientific evidence, political imperatives, and stakeholder interests. These examples reveal how evidence can be selectively used to support pre-determined policies, leading to "decision-based evidence making," and how strong economic incentives can divert practice patterns from evidence-based priorities.
Systemic barriers, including insufficient research funding and quality, accessibility issues, the disconnect between research and policy needs, and conflicts over values, have been identified as pervasive challenges. However, the review also points to crucial facilitators, such as policymaker demand for evidence, stakeholder engagement, and the use of deliberative processes.
Strengthening evidence utilization in Korean healthcare demands a comprehensive and integrated approach. This involves not only enhancing the research infrastructure and ensuring the accessibility of high-quality, context-specific evidence but also fostering institutional mechanisms like robust Health Technology Assessment. Crucially, it requires cultivating a culture of genuine evidence-informed policy-making through education, transparent deliberative processes, and a commitment to integrating diverse forms of evidence, including the often-overlooked colloquial evidence and critical societal values. By addressing these multifaceted aspects, Korea can move towards a more sustainable, equitable, and effective healthcare system that truly serves the health needs of its population.
Notes
Conflict of Interest
No potential conflict of interest relevant to this article was reported.
Data Availability Statement
All data generated or analyzed during this study are included in this published article and its supplementary information files.
Ethics Approval and Consent to Participate
Not applicable.
Authors Contributions
All the work was done by Sang-il Lee.
Table 1.Typology of Evidence in Healthcare Decision-Making
|
Type of evidence |
Key characteristics |
Primary source examples |
Role in decision-making |
|
Scientific (Context-free) |
Explicit, Systematic, Replicable; Universal applicability |
Randomized Controlled Trials (RCTs), Systematic reviews, Meta-analyses |
Establishes general efficacy/safety of interventions |
|
Scientific (Context-sensitive) |
Adapted to local context; Addresses implementation, economics, ethics within a setting |
Cost-effectiveness analyses, Real-world data, Implementation studies |
Informs practical application, feasibility, and local impact |
|
Colloquial |
Non-systematic, Reflects values/experience; Often the only available input |
Expert testimony, Professional opinion, Political judgment, Policy reports, Stakeholder views, Patient experiences |
Supplements/refutes scientific evidence; Integrates societal values and practical constraints |
Table 2.Key Challenges and Facilitators for Evidence Use in Korean Healthcare Policy
|
Category |
Specific barriers |
Specific facilitators |
|
Evidence production |
Insufficient research period and funding; Low quality and reliability of research; Dearth of timely, context-specific domestic research |
Sufficient research period and funding; Enhanced quality and reliability of research; Focus on context-specific domestic research |
|
Evidence dissemination & accessibility |
Low accessibility to research findings for policymakers; Absence of dedicated dissemination organizations/programs |
Establishment of dedicated dissemination organizations/programs; Enhanced accessibility of findings for policymakers |
|
Translational capacity |
Difficulties translating complex analysis results into actionable knowledge |
Simplification of methodology; Development of practical good practice guidelines |
|
Organizational & resource constraints |
Limited knowledge and expertise among staff; Insufficient time and financial resources for evidence engagement |
Building internal capacity for analyses; Provision of adequate time and resources |
|
Policy-Research Interface |
Evidence used for rationalization/legitimization of pre-decided policies ("Decision-Based Evidence Making"); Gap between policy needs and research output |
Policymaker demand for evidence; Establishment of independent expert bodies (e.g., for workforce projections) |
|
Value & Equity integration |
Overemphasis on efficiency, challenging integration of equity/justice |
Usage of value-based appraisal methods; Deliberative processes for negotiating values |
|
Generalizability & timeliness |
Research (e.g., RCTs) not always relevant/generalizable to diverse populations/complex cases; Time lag between research and application |
- (Implicitly addressed by focus on context-sensitive research) |
|
Behavioral & political factors |
Confirmation bias among practitioners/policymakers; Entrenched stakeholder interests; "Strong vs. strong" confrontations |
Educational interventions for critical appraisal; Stakeholder and public engagement; Parliamentary mediation/social consultative bodies |
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