PHWR Public Health Weekly Report

The outbreak of Middle East Respiratory Syndrome in 2015 prompted a significant overhaul of Republic of Korea’s (ROK’s) national infectious disease response system. However, the unprecedented global coronavirus disease 2019 (COVID-19) pandemic from 2020 demanded whole-of-government and all-of-society mobilization far beyond the existing frameworks. Notably, when infectious diseases spread primarily within communities, collaborative response capabilities with local governments, rather than unilateral directives from the central government, prove pivotal in safeguarding public health and lives.

However, many local governments struggled with the initial response owing to shortages of specialized personnel, limitations in stockpiling disease control supplies, and disparities in epidemiological investigation capacities [1]. These challenges highlighted the need for institutional and organizational foundations enabling local governments to function not merely as implementing agencies but as “on-site control towers” for infectious disease responses.

Given the continued risks of emerging and re-emerging infectious diseases amid climate change and increasing international mobility, ongoing institutional improvements and policy support for a community-based infectious disease prevention and control system are imperative to ensure timely and sustainable responses.

This study reviewed the current institutional status of the central government, led by the Korea Disease Control and Prevention Agency (KDCA), and the infectious disease prevention and management systems of the local governments based on relevant legislation, including the Infectious Disease Control and Prevention Act, Local Autonomy Act, and Framework Act on Government Performance Evaluation, as well as key policy documents, such as the COVID-19 Response White Paper. Furthermore, in response to the limitations of recent infectious disease crisis management, this study identified ongoing efforts to address these shortcomings and key future tasks necessary for strengthening community-level response capacities.

1. Roles and Structures of Central and Local Governments

According to Article 4 of the Infectious Disease Control and Prevention Act, both central and local governments are responsible for the prevention and management of infectious diseases. Under Article 11 of the Act, the KDCA establishes a basic plan every five years. The basic plan includes fundamental goals, strategic directions, and projected plans for the prevention and management of major infectious diseases. Subsequently, provincial and municipal governments develop their own implementation plans based on the basic plan. This institutional arrangement formalizes the functional linkage between the central and local governments, thereby balancing policy consistency with regional specificity.

Moreover, the roles of central and local governments are delineated according to the statutory classification system of infectious diseases. In the case of first-class infectious diseases, which rarely occur but have high fatality rates or a significant risk of rapid spread, the Central Disease Control Headquarters, led by the Commissioner of KDCA, assumes direct command and control to minimize the impact. Local governments execute on-site operations in response to central government guidelines. In contrast, for second- and third-class infectious diseases, which occur more frequently and have established management protocols, local governments lead the surveillance and control efforts, with the central government providing technical and financial support as necessary. Notably, the central government issues detailed guidelines for the diverse infectious disease programs undertaken by local governments.

This surveillance and response framework allows for a unified command structure at the national level during crises, while enabling flexible, region-specific responses during routine management periods.

2. Strengthening Field-based Infectious Disease Response Foundations

In September 2020, the KDCA established five Regional Centers for Disease Control and Prevention (RCDCs) to bolster local response capacities and strengthen linkages between the central and local governments. These centers are located in the Seoul metropolitan area and four other regions (Chungcheong, Honam, Gyeongbuk, and Gyeongnam). The RCDCs serve as a regional hub overseeing local infectious disease surveillance, epidemiological investigation support, management of specialized infectious disease hospitals, and stockpiling and managing response resources. Established to prepare for the spread and large-scale transmission of infectious diseases within communities, each RCDC is designed to cover adjacent living zones and reinforce regional-level response systems. While the KDCA headquarters functions as the national control tower responsible for overall policy planning and coordination, the RCDCs work in close collaboration with local governments, forming a field-oriented response base [2].

Additionally, under Article 8 of the Infectious Disease Control and Prevention Act, each of the 17 provinces operates a Provincial Infectious Disease Control Support Group composed of healthcare professionals and experts (Figure 1). These groups provide planning support for local infectious disease programs, collect and analyze outbreak data, implement training and public awareness campaigns, and assist in emergency field responses during crisis situations (when the infectious disease disaster alert reaches “caution” or higher levels) [1].

Figure 1. Operational structure of the Provincial Infectious Disease Control Support Group

Despite these multilayered structures, comprising the KDCA headquarters, RCDCs, provincial governments, and municipal governments (Figure 1), there remain areas needing reinforcement, in particular, the RCDC’s roles and capabilities. Challenges include the limited delegated authority and diagnostic/analytical functions confined to quarantine zones. While the Provincial Support Groups contribute meaningfully to regional preparedness and help reduce disparities in local response capacity, the RCDCs must further evolve into core regional hubs with expanded mandates and enhanced capacity to lead localized infectious disease response strategies.

3. Roles and Limitations of Local Governments

Local governments, guided by the central government’s fundamental policies, play a pivotal role in the prevention and management of infectious diseases within their communities. Primarily, the local governments establish and implement infection prevention policies and quarantine measures at the regional level, while supporting medical care and protection services for infectious patients. Additionally, they conduct region-specific data collection, analysis, and dissemination to facilitate infectious disease surveillance and research. Local governments also focus on training infectious disease specialists, stockpiling and managing medical and quarantine supplies to prepare for emergencies, and conducting education and public awareness campaigns aimed at prevention.

Despite these substantive roles, the organizational and human resource capacities for infectious disease responses at the local level remain fragile. Notably, a workforce imbalance exists across regions. Although disparities in public health personnel between metropolitan and basic local governments have always been evident, a particularly wide variation in the number of epidemiologists employed has been observed. According to Article 60 of the Infectious Disease Control and Prevention Act and Article 35 of its Enforcement Decree, each province must assign at least two epidemiologists, while municipalities with populations exceeding 100,000 must employ at least one qualified epidemiologist. However, many local governments are yet to meet these mandatory staffing requirements (Figure 2).

Figure 2. Current status of epidemiologic investigator deployment

In cases of urgent infectious disease outbreaks or widespread epidemics, Article 60-3 (Temporary Work Orders) of the same Act authorizes the appointment of quarantine officers and epidemiologists for specific periods to perform their duties. To support this framework, Article 18-5 (Implementation of Infectious Disease Education) was introduced in 2023, mandating that central and local government officials receive annual training on infectious disease prevention, management, and crisis response, with the training results to be submitted to the Commissioner of the KDCA.

Furthermore, workforce instability before and after the pandemic has posed significant challenges. During crises, such as the COVID-19 pandemic, frontline workers face heightened infection risks and excessive workloads, resulting in job avoidance, burnout, and leaves of absence. In response, the government implemented “Mind Pause,” a burnout management program, to support response personnel.

4. Performance Management and Incentive Policies of the Central Government

The KDCA conducts an annual evaluation of local governments’ infectious disease prevention and management efforts in accordance with the Framework Act on Government Performance Evaluation. Particularly since 2023, when COVID-19 transitioned to an endemic phase, the KDCA initiated a research project to develop “evaluation indicators for infectious disease prevention and management in local governments.” This initiative aimed at strengthening community-level preparedness and response capacities in anticipation of potential future pandemics and ongoing infectious disease management.

This study analyzed major central government policy directions and the specific characteristics of local government operations within the infectious disease sector, resulting in the formulation of 76 evaluation indicators designed to ensure consistency in policy objectives. Building on these findings, the evaluation indicators underwent a comprehensive revision in 2024, incorporating feedback from past assessments, pandemic response experiences, and research outcomes, thereby establishing the current evaluation framework.

The revised evaluation targeted 17 metropolitan and basic local governments and comprised four main domains as follows: Capacity Building (e.g., participation rate in emerging infectious disease crisis response training, infectious disease response education completion rate, and number of epidemiologists completing specialized courses in provinces); Infectious Disease Prevention and Management (e.g., compliance with statutory infectious disease reporting, public communication, completeness of epidemiological investigations); Organizational Structure and Operations (e.g., establishment of dedicated infectious disease response departments and the ratio of dedicated personnel within infectious disease management units); and Exemplary Cases of Infectious Disease Prevention and Management at the Local Government Level.

The establishment of these evaluation indicators functions as a mechanism to guide local governments toward enhancing their infectious disease management capacities in alignment with the central government policy, while promoting a standardized level of response across regions. For instance, indicators such as the number of epidemiologists completing specialized courses and the establishment of dedicated infectious disease departments effectively encourage the strengthening of practical response capabilities at the local level. The evaluation results are shared annually at the KDCA-hosted Infectious Disease Management Conference, where outstanding local governments are recognized for government awards and institutional commendations. The conference serves to disseminate the latest trends and best practices in infectious disease control, and to publicly acknowledge local governments’ performance, thereby fostering healthy competition among regions and encouraging the achievement of policy goals.

The COVID-19 pandemic highlighted the critical importance of organic collaborations between the central and local governments in the ROK. Institutional advancements have been made in the infectious disease response system, including the establishment of five RCDCs and the restructuring of the local governments’ evaluation systems. These efforts positively strengthen the functional connectedness between the central and local governments. However, structural limitations persist in the field, such as shortage of specialized personnel, disparities in response capacities among the regions, and unclear roles between institutions [1]. Therefore, continuous improvement is necessary to effectively enhance community-centered infectious disease response capabilities.

To improve the effectiveness of infectious disease responses, clear role distinctions between the central and local governments must be accompanied by functional coordination and distribution of responsibilities. The central government should act as a command system responsible for overarching strategies and resource allocation. In contrast, local governments should serve as rapid implementers that excel in considering regional characteristics and on-the-ground conditions.

The institutional framework for infectious disease planning and legal responsibilities shared between central and local governments ensures a balance between policy consistency and regional specificity. The RCDCs serve as a key node linking central and local governments. For more effective operations, role clarifications, strengthening of the regional centers’ functions, and enhancing local governments’ field-response capacities are essential.

First, the central government needs to systematically integrate and organize extensive Standard Operating Procedures and guidelines to enable frontline personnel to swiftly apply them in various situations. Currently, more than 30 separate infectious-disease-related guidelines are revised annually. Providing systematic and clear operational manuals will support local governments in performing their tasks consistently and smoothly. This will help maintain a certain level of response capacity even for newly recruited or temporary personnel who lack prior experience. The KDCA supplements and publishes the Infectious Disease Management Manual annually. This manual covers surveillance systems, epidemiological investigations, laboratory testing, patient and contact management, and vaccinations [3]. Continuous support is necessary to enable local government officials to perform their duties quickly and accurately.

Second, RCDCs must evolve beyond their current limited roles by redefining their functions and developing new responsibilities to serve as hubs for creating region-specific response strategies. To this end, the KDCA commissioned a research project in 2025 to strengthen the roles and functions of these regional centers [2]. Based on the findings, the regulatory basis for the existence of centers needs to be clarified through the development of execution and regulatory tasks. Communication between the regional centers and headquarters must be enhanced by jointly reviewing and planning specialized projects. Moreover, these centers need to provide tangible services as perceived by local governments and the public, and maintain collaborative networks within their regions.

Third, local governments should establish dedicated infectious disease response units and build a stable operational system that enables trained professionals to work over the long term. Flexible personnel management plans tailored to each local government’s circumstances are necessary to minimize workforce burnout during crises, such as pandemics. Efforts should be made to assign at least two epidemiologists per metropolitan city and one per county/district with populations exceeding 100,000 as stipulated in Article 60 of the Infectious Disease Control and Prevention Act. In urgent situations, such as new infections or infectious disease outbreaks, detailed measures should allow temporary appointments of quarantine officers and epidemiologists [4]. Additionally, practical, field-oriented training in epidemiological investigations, patient transport, and disinfection should be strengthened to ensure skilled responses, even in disaster scenarios.

Fourth, the central government must continuously review and improve infectious disease prevention and management evaluation indicators to reduce regional disparities and encourage local capacity-building. Indicators that meet the target levels should be adjusted or replaced with metrics that reflect new national agendas or qualitative achievements. In 2024, the KDCA conducted working-level meetings with relevant departments and local governments to collect feedback, which should be institutionalized as a regular process.

The evaluation indicators serve as a compass for local governments’ policies and initiatives, securing policy coherence between the central and local levels, and enhancing the consistency of infectious disease response systems.

When these improvements proceed in parallel, a sustainable infectious disease response system with organic cooperation between central and local governments can be established. Such a system aims to operate as a robust public health infrastructure capable of protecting the health and safety of the population, even in the face of emerging infectious diseases. However, this study primarily focused on the literature and institutional analyses of the structure and policies of infectious disease response systems. It did not quantitatively analyze the actual response conditions or specific outcomes of local government operations. Future research should incorporate quantitative evaluation data from local governments along with qualitative data based on practitioners’ experiences to empirically assess how institutional improvements are realized in the field.

Ethics Statement: Not applicable.

Funding Source: None.

Acknowledgments: None.

Conflict of Interest: The authors have no conflicts of interest to declare.

Author Contributions: Conceptualization: MSK, HYK, JH. Supervision: JH. Writing – original draft: MSK, HYK, JH. Writing – review & editing: MSK, HYK, JH.