PHWR Public Health Weekly Report

Tuberculosis (TB) is an infectious disease transmitted through the respiratory tract during common activities such as coughing, sneezing, talking, and singing. As a leading cause of chronic respiratory infections, TB requires a minimum of 6 months of treatment. To combat this challenge, the Korean government develops a comprehensive TB control plan every 5 years to manage TB cases and ultimately eradicate the disease. Currently, the country is in the third year of implementing its “Third Comprehensive TB Control Plan (2023–2027)” [1].

However, patients may discontinue treatment due to factors such as prolonged treatment duration and therapy-associated adverse effects. In such cases, TB becomes not just a personal issue but a public health concern, as the bacteria can be transmitted to others. Consequently, the right to refuse treatment is no longer solely an individual matter but can be a ground for restricting fundamental rights in the interest of public welfare (Article 37, Paragraph 2 of the Constitution) [2]. This situation requires a minimal level of institutional intervention, such as the hospitalization order system, which aims to prevent the spread of TB among non-compliant patients. However, since this measure inevitably restricts individuals’ rights for the greater public good, it must be supported by appropriate social assistance.

In this context, although the Republic of Korea (ROK) incorporated a “hospitalization order” clause in the Tuberculosis Prevention Act enacted in 1967, specific implementation guidelines were lacking for a considerable period. It was not until April 2011 that a centralized, systematic management and support system was officially launched [3]. This report aims to explore the background of the hospitalization order system for patients with TB introduced in 2011, its key milestones, and its current state of implementation.

To explore the history of the TB hospitalization order system, a review was conducted of key legal documents, including the Tuberculosis Prevention Act and the Public Notice on Measures to Protect the Livelihood of Dependents. Major policy initiatives, such as Eradicating Tuberculosis 2030 and its revision, were also examined. Additionally, annual editions of the National Tuberculosis Management Guidelines and Tuberculosis Treatment Guidelines were analyzed. To assess the current status of those who issued hospitalization orders, TB report data from the Integrated Tuberculosis Management System and issuer registration data were collected. This information was used to evaluate the annual number of hospitalization orders, their proportion relative to all TB cases, and the frequency and distribution of each case type.

1. Key Milestones of the Hospitalization Order System

The Tuberculosis Prevention Act was enacted in 1967 and came into effect in January 1968. Although the law included a provision for issuing a “hospitalization order,” it lacked detailed guidelines for implementation and economic support measures.

To improve treatment adherence among non-compliant patients, the need arose for economic support to accompany the mandatory administrative action of hospitalization orders. This need became more pressing with the increasing number of patients with multidrug-resistant TB (MDR-TB), whose treatment duration is more than three times longer than that of drug-susceptible TB (DS-TB). In response, Eradicating Tuberculosis 2030 was introduced in 2006 to provide financial support for medication, thereby improving treatment adherence among patients with MDR-TB. In March 2008, the Eradicating Tuberculosis 2030 Revision established a basic plan to cover medical expenses, including isolation treatment for non-compliant patients and those with MDR-TB [4].

In 2010, the Tuberculosis Prevention Act was comprehensively revised to include detailed standards for implementing hospitalization orders and economic support. Following this revision, a budget for the Support Program for Patients with Tuberculosis under Hospitalization Order was secured by the end of the year.

With both legal and financial frameworks in place, the Support Program for Patients with Tuberculosis under Hospitalization Order was officially launched in April 2011 under Article 15 (Hospitalization Order) of the Tuberculosis Prevention Act. Furthermore, the Notification on Livelihood Protection Measures for Patients with Tuberculosis Under Hospitalization or Isolation Orders and Their Dependents was enacted, offering compensation for income loss due to hospitalization or isolation treatment [5].

In 2014, a partial amendment to the Tuberculosis Prevention Act made it mandatory for patients who refused hospitalization or were discharged against medical advice to comply with an “isolation treatment order.” It also authorized local governments to request police assistance in enforcing this order (Article 15-2).

Moreover, the amendment introduced an investigation process to identify dependents eligible for livelihood protection measures (Article 16-2).

2. Key Milestones Related to Support for Individuals Subject to Hospitalization Orders

The World Health Organization permits involuntary isolation of patients with TB only after all other measures have been exhausted [6]. Therefore, the implementation of the hospitalization order system must be accompanied by supplementary measures that address the associated restriction of basic rights. The main forms of financial support provided to individuals under hospitalization orders include coverage of hospitalization costs (including nursing care), out-of-pocket medication expenses, and livelihood support for dependent family members. Hospitalization and medication costs are considered medical expenses incurred during the period of isolation treatment. Livelihood support for dependents is a government-provided social welfare benefit that partially compensates for income lost during the treatment period. These measures were introduced alongside the launch of the system in 2011 and have since been revised with ongoing expansions to minimize the financial burden on patients (Table 1).

Table 1 Support for TB patients with hospitalization order

Category	① Medical expenses (unit: ten thousand won)	② Caregiver’s cost (unit: won)	③ Drug expenses (full out-of-pocket)	④ Living expenses for dependents
2011. 4.	-. Co-payment. -. Non-covered servicea)‧full out-of-pocketb): within upper limit/yr. ·. MDR-TB (300–500/yr). ·. Non-compliant (70/yr).	-. 10,000/day(① within upper limit/yr).	-. Non-covered anti-TB drug costs.	-. (Criteria) less than 300% of minimum cost of living (by household). -. (Benefit) cash benefit of minimum cost of living.
2013. 1.	※ Non-compliant: rasing the upper limit (70→100/yr)	Same	※ Support expansion. -. Linezolid drug cost(cost) 70,000 won/day, (duration) maximum untill 2 yr.	Same
2016. 7.	-. Exemption from co-payment (benefit extension policy to TB).	Same	Same	-. (Criteria) less than 120% of median income (by household).
2017. 9.	Same	Same	-. Full covered under the national health insurance.	Same
2019. 1.	Same	-. 100,000/day.	Same	Same
2020. 1.	Same	-. 150,000/day.	Same	Same
2024. 1.	Same	※ Setting the upper limit/yr	Same	Same

TB=tuberculosis; MDR-TB=multidrug-resistant TB. ^a)Physician surcharge, advanced room charges, caregiver’s cost etc. ^b)Payroll expenses where you pay the full cost of covered expenses..

1) Hospitalization Costs

When the system was first implemented, the government fully covered the statutory out-of-pocket expenses, as well as a portion of non-covered expenses incurred during the mandated hospitalization period. The coverage of non-covered expenses was capped based on the type of TB.

For patients with MDR-TB, particularly chronic carriers and non-compliant patients who require long-term treatment, national TB guidelines recommend early admission to and treatment at national TB hospitals. This approach enables vulnerable patients to remain hospitalized and receive treatment until they are no longer infectious without facing additional financial burdens. Beginning in July 2016, as part of the third phase of the National Health Insurance Mid-term Coverage Expansion Plan (2014–2018), co-payment exemptions were introduced for TB-related medical expenses. This policy effectively eliminated all out-of-pocket costs under a special case provision (Figure 1).

Figure 1. The numbers and portion of the hospitalization order with MDR-TB cases
TB=tuberculosis; MDR-TB=multidrug-resistant TB; RR TB=rifampicin-resistant tuberculosis. ^a)MDR-TB (2011–2021): TB resistant to both rifampicin and isoniazid. ^b)MDR/RR TB (from 2022): TB resistant to rifampicin alone or both rifampicin and isoniazid.

2) Nursing Care Costs

Initially, support for nursing care costs was provided at a fixed monthly rate of 300,000 KRW, equivalent to approximately 10,000 KRW per day. This rate was maintained until 2018. However, as the population of patients with TB patient aged and the demand for nursing care increased, alongside a sharp rise in private care costs due to isolation treatment at private medical institutions, the need to revise the payment rate became evident. Following two guideline revisions in 2019 and 2020, the rate was raised to 150,000 KRW per day.

Since July 2016, all out-of-pocket medical expenses have been fully waived under the expanded special co-payment exemption policy for TB, with non-covered costs supported through the program budget. Consequently, patients now bore minimal to no financial burden for medical expenses. However, nursing care costs were not included in this exemption, and until the payment rate was adjusted, patients incurred considerable out-of-pocket expenses for nursing services.

A study analyzing treatment success rates among vulnerable patients with TB, supported under the Tuberculosis Safety Belt Project, part of the National Tuberculosis Prevention Private Support Program (2014–2018), revealed that patients with comorbidities had lower treatment success rates than those without. The study also found that the likelihood of treatment success decreased as the number of comorbid conditions increased [7]. Moreover, patients with comorbidities faced challenges in gaining admission to national TB hospitals. To address this issue, it is necessary to designate suitable medical institutions capable of diagnosing and treating both TB and accompanying conditions, provide appropriate hospitalization services, and establish a support system tailored to the needs of vulnerable patients. Until a nationwide support system for vulnerable patients with TB is fully established, the hospitalization order system appears to have only partially met their needs.

3) Out-of-pocket Medication Costs

MDR-TB poses a significant treatment and management challenge for both patients and medical staff due to the limited range of effective medications and the typically prolonged treatment period, which often exceeds 2 years. At the time, medications such as linezolid (entirely out-of-pocket) and clofazimine (not covered), classified as Group 5 drugs under the treatment guidelines, were not part of the standard regimen and were used selectively for intractable TB cases. Patients prescribed these medications were responsible for the full cost [8].

Providing financial support for these high-cost medications, both reimbursed and non-reimbursed anti-TB drugs has been critical to the successful treatment of MDR-TB, including extensively drug-resistant TB.

In 2013, government funding was expanded to cover these out-of-pocket medication costs at a rate of 70,000 KRW per day for up to 2 years (including post-discharge). This review significantly reduced the financial burden on patients. In September 2017, a revision of the reimbursement standards for linezolid, along with the application of a special co-payment exemption policy for TB, significantly expanded medication cost coverage for patients with MDR-TB.

4) Livelihood Support for Dependent Family Members

The purpose of providing support for dependent family members is to compensate for income lost during the isolation period of a patient with TB (or household) subject to a hospitalization order. The Tuberculosis Prevention Act mandates that such measures be taken for individuals under the hospitalization order (Article 16). If the hospitalized patient is determined to be the primary income earner and has experienced income loss, livelihood support is provided based on the minimum cost of living standards for each household, as announced annually by the Ministry of Health and Welfare. Eligibility for this support is determined through a prior income assessment. Initially, the selection criteria were based on the “minimum cost of living per household,” but in January 2016, this standard was revised to “median income.” As a result, eligibility criteria for all welfare recipients, including families of patients with TB under hospitalization orders, were unified under the median income standard. Specifically, the threshold for receiving livelihood changed from “less than 300% of the minimum cost of living per household” to “less than 120% of median income.”

3. Program Implementation System

According to Articles 15 and 15-2 of the Tuberculosis Prevention Act, the entities responsible for issuing hospitalization orders are the heads of the local governments, including provinces, cities, counties, and districts. The management system for hospitalization orders is illustrated in Figure 2.

Figure 2. Governance and procedure of hospitalization orders with TB patients
TB=tuberculosis.

The main stakeholders involved include the public health centers responsible for managing patients with TB based on their registered address (hereinafter referred to as the patient management health center), medical institutions providing inpatient and isolation treatment, and individuals subject to hospitalization orders.

The procedures of the program are as follows: 1) The patient management health center receives a notification from a medical institution regarding an individual TB case. 2) The center reviews the case and confirms the need for hospitalization. 3) If hospitalization is deemed necessary, the patient is issued a hospitalization order and provided with guidance on the required steps. 4) The patient then undergoes isolation treatment until an official notice of release is issued. 5) The medical institution provides treatment until the patient is no longer infectious, conducts TB testing, and submits a hospitalization order release opinion to the patient management health center. 6) The center reviews the release opinion and, upon confirmation, officially terminates the hospitalization order.

4. Current Status of the Hospitalization Order System

This report focuses on the current status of the hospitalization order system, specifically cases where the head of a local government issued an administrative order in accordance with the Tuberculosis Prevention Act.

To assess this, TB case reports and hospitalization order registries collected through the Integrated Tuberculosis Management System were analyzed. The number of hospitalization order cases from 2011 to 2023 was compared with the total number of TB cases each year, as reported in the Annual Report on Tuberculosis Notifications published every March [9].

Table 2 presents the number of hospitalization orders issued by heads of local governments under Article 15 of the Tuberculosis Prevention Act from the system’s launch in 2011 through 2024. Since 2011, an average of 300 individuals (range: 163–620) have been hospitalized annually, totaling approximately 5,400 patients by 2024. This figure represents an average of 1% (range: 0.7–1.4%) of the annual population of patients with TB.

Table 2 TB cases and number of hospitalization orders by type

Category	Total			Hospitalization ordered
				Sub total			MDR-TB			Non-compliant			Othersa)
	TB cases	Hospitalization orders		n	%		n	%		n	%		n	%
2011	50,491	329 (0.7)		329	100		184	55.9		145	44.1		-	-
2012	49,532	472 (1.0)		472	100		335	71.0		137	29.0		-	-
2013	45,292	571 (1.3)		571	100		459	80.4		112	19.6		-	-
2014	43,088	620 (1.4)		620	100		497	80.2		123	19.8		-	-
2015	40,847	574 (1.4)		574	100		425	74.0		149	26.0		-	-
2016	39,245	562 (1.4)		562	100		383	68.1		170	30.2		9	1.6
2017	36,044	447 (1.2)		447	100		303	67.8		96	21.5		48	10.7
2018	33,796	396 (1.2)		396	100		276	69.7		83	21.0		37	9.3
2019	30,304	367 (1.2)		367	100		225	61.3		85	23.2		57	15.5
2020	25,350	278 (1.1)		278	100		163	58.6		63	22.7		52	18.7
2021	22,904	219 (1.0)		219	100		140	63.9		45	20.6		34	15.5
2022	20,383	175 (0.9)		175	100		119	68.0		22	12.6		34	19.4
2023	19,540	223 (1.1)		223	100		125	56.1		31	13.9		67	30.0
2024	17,944	163 (0.9)		163	100		79	48.5		24	14.7		60	36.8

Unit: number (%). TB=tuberculosis; MDR-TB=multidrug-resistant TB. ^a)Where the Mayor/Do Governor or the head of each city/county/district deems that a TB patient need to be hospitalized for isolation treatment at a medical institution (a vulnerable Patient with acid fast bacilli positive susceptible TB, including elderly)..

Based on the classification standards in the National Tuberculosis Management Guidelines, individuals subject to hospitalization orders are grouped into three categories: patients with MDR-TB, non-compliant patients, and others. The “others” category, cases in which the local government determines the necessity of hospitalization, has been tracked separately in the Integrated Tuberculosis Management System since 2016. Table 2 provides the annual breakdown by type.

In 2023, 223 (1.1%) out of 19,540 total patients with TB were issued hospitalization orders. Among them, 125 patients (56.1%) had MDR-TB, 31 (13.9%) were non-compliant, and 67 cases (30.0%) were classified as “others” by the local government.

From 2011 through 2015, patients with MDR-TB accounted for up to 80% of all hospitalization orders. This trend aligns with the objectives outlined in Eradicating Tuberculosis 2030 and its revision, which prioritized support for patients with MDR-TB. However, during the subsequent implementation process, the proportion of non-compliant patients and those classified as “others” gradually increased. This shift is largely attributed to the July 2016 expansion of the TB special co-payment exemption, which eliminated out-of-pocket costs for TB management. Additionally, in 2017, linezolid, a costly second-line drug, was included under reimbursement, significantly reducing the financial burden on patients with MDR-TB and leading to a decline in hospitalization orders for this group. Moreover, the aging population potentially contributed to an increase in older patients with DS-TB requiring hospitalization.

Meanwhile, isolation treatment orders issued under Article 15-2 of the Tuberculosis Prevention Act have been tracked since 2014, with an average of two cases per year, totaling 20 by 2024.

This report examined the background, key milestones, and operational status of the hospitalization order system for patients with TB.

Given that TB treatment can take several months to years, early diagnosis and uninterrupted treatment with appropriate medications are critical to minimizing transmission. In particular, drug-resistant TB presents significant treatment challenges, and the spread of MDR strains poses a major public health risk, necessitating institutional intervention.

Since 2011, ROK has implemented a hospitalization and isolation system for patients with TB. Under Articles 15 and 15-2 of the Tuberculosis Prevention Act, local government heads may issue hospitalization orders for patients with MDR-TB or non-compliant patients. During isolation, patients may receive treatment at designated medical institutions almost free of charge, supported by special co-payment exemptions and the isolation treatment support system.

Financial support is also available for hospitalization, medications, and income loss during isolation. This support enables even day laborers, who are at risk of treatment interruption, to complete their treatment without undue financial burden.

Although the Tuberculosis Prevention Act originally included provisions for isolation orders, detailed operational and financial support plans were established in the 2006 Eradicating Tuberculosis 2030 and its 2008 revision. These plans laid the groundwork for the full revision of the law in 2010, budget allocation, and system implementation in 2011. In 2014, the Tuberculosis Prevention Act was further amended to include provisions for isolation treatment orders for those who refused hospitalization orders and to allow for police cooperation in such cases.

The scope of support has steadily expanded. For instance, the 2016 expansion of TB special co-payment exemptions eliminated all out-of-pocket medical expenses for patients. In 2017, the inclusion of costly second-line drugs such as linezolid under the exemption extended benefits further. Nursing care costs, which had posed a significant financial burden, were also adjusted in 2019 and 2020 to more realistic levels, reducing financial pressure on isolated inpatients.

By combining administrative enforcement with economic support, the hospitalization order system under the Tuberculosis Prevention Act has played a critical role in ensuring treatment completion and preventing community transmission. Moreover, it contributed to the stable implementation of support programs for vulnerable patients with TB (e.g., the “Tuberculosis Safety Belt” project), serving as a model for financial aid.

However, this report is limited in scope, focusing only on the background and operation of the hospitalization order system following the enactment of the Tuberculosis Prevention Act. It did not assess the system’s impact on treatment success rates or suggest future policy directions. Further research is needed to develop improvement measures and inform policy recommendations.

Ethics Statement: Not applicable.

Funding Source: None.

Acknowledgments: None.

Conflict of Interest: Young-Joon Park is an editorial board member of the journal, but was not involved in the review process of this manuscript. Otherwise, there is no conflicts of interest to declare.

Author Contributions: Conceptualization: YJP, JYH. Data curation: JTK. Formal analysis: JYH, JTK. Investigation: JYH. Methodology: YJP, JYH. Visualization: JYH. Writing–original draft: JYH. Writing–review & editing: JHJ, SYS, YJP.