NCD Non-Communicable Disease
OECD Organisation for Economic Co-operation and Development
OHCHR Office of the United Nations High Commissioner for Human rights
ROK Republic of Korea, ROK
UN United Nations
WHO World Health Organization
Suicide is a leading cause of death in the world (WHOa, 2018). Globally approximately 800 000 people annually take their lives which equates to one person dying every 40 seconds (WHOa, 2018). Even though suicide is not a disease, its negative influence on family and communities cannot be ignored. In 2013, WHO acknowledged that preventing suicide should be prioritized, and announced Mental Health Action Plan 2013 –2020 (WHOb, 2013). In this plan, Global target 3.1. aims that 80% of countries will have at least two functioning national, multisectoral promotion and prevention programmes in mental health by the year 2020 (WHOb, 2013). Global target 3.2. aims to reduce the rate of suicide in countries by 10% by 2020 (WHOb, 2013). With this long-term plan for preventing suicide globally, the overall rate of suicide worldwide has fallen since 2000, with a reduction of 2.3 per 100 000 population, partially due to improvement of general global health state (WHOa, 2018). However, the decreasing trend of suicide rate is different by nations and regions (WHOa, 2018).
This policy brief will focus on Republic of Korea (ROK), where is the highest suicide rate among OECD members (OECDa, 2018), The Korean government, a member county of WHO, has proposed strategies (5-year plan) including mental health care to reduce the suicide rate on a governmental level. Unfortunately, its preventative effect was not remarkable as stated by some scholars (Roh et al., 2016, Lee, 2015, Garg and Kothari, 2018).
The overall rate of suicide in ROK has fluctuated between 26.8% and 34.1% since 2000 (KOSIS, 2018). According to a report by the National Statistical Office in 2017, the leading cause of death in Koreans between the ages 10 and 30 is suicide, with only a 0.7% reduction between 2007/17 (KOSIS, 2018). When quantified the burden of suicide with the disability-adjusted life year (DALY) (Murray and Acharya, 1997), DALY in 2016 increased more than five times compared to 2000, rising from 100.6 to 538.9 (WHOc, 2018). This growth rate is considerably higher than Japan, where suicide rates were as much as ROK now in a declining trend after adopting preventative actions, with a three times DALY increase between 2000/2016 (WHOc, 2018).
Regarding the 5-year plan’s ineffectiveness, some scholars point out the government’s fiscal plan of mental health area as a reason(Roh et al., 2016, Lee, 2004 a, Lee, 2015 b). In fact, while ROK only spent $7 million on mental health in 2016, 64% addressed to hospitals and other mental institutions, Japan spent nearly $130 million on prevention of suicides and promoting awareness (Garg and Kothari, 2018). The annual expenditure on mental health sector is substantially smaller than in Japan, but pouring money is not the best solution (Garg and Kothari, 2018). It is important to devise a multifactorial approach to suicide and cost-effective interventions within limited budget. After engaging in the Sustainable Development Goals (SDGs), the government faced a challenge in reducing around 30% NCD-related premature mortality through prevention, treatment of mental health and promoting well-being by 2030 (Nations, 2016). To achieve these goals, more cost-effective intervention should be adopted. This policy brief will introduce several cost-effective interventions.
1. Suicide is preventable but requires a multifactorial approach (WHOb, 2013). For instance, controlling accessibility to pesticides, one of the reported tools of self-poisoning, which has significantly decreased suicide rates in Sri Lanka (Knipe et al., 2017). Additionally, some studies have proven that restricting self-harm messages in media is also related to a reduction in suicide contagion, copycat suicide, in Austria (Niederkrotenthaler and Sonneck, 2007). Therefore, interventions using a multifactorial approach are needed to prevent suicide.
2. Suicide widely impacts the economy and development of the nation. The Health Insurance Policy Research Institute of the National Health Insurance Service states that the total social loss due to suicides each year would be estimated at US $5,9118 billion (Garg and Kothari, 2018, KDI, 2018). Given that 90% of the people who commit suicide had mental (Garg and Kothari, 2018), the increasing burden of mental health does not seem good with estimated social loss at US$ 6.3 billion in 2020 (Yoon, 2018). Considered costs including trauma caused failed suicide attempts and costs of treating physical, psychological disorder of bereaved family, the total socioeconomic cost would be higher than the estimated cost (Lee et al., 2017).
3. The establishment of targeted preventive measures, especially for youth and workers, is urgent. People from ages 15 to 64 are productive population who lead economic, societal development of a country (OECDb, 2018). As health and economic growth are interlinked (Frenk, 2004), when the burden of suicide is high in an economically productive population, it is hard to achieve sustainable growth due to large loss of socioeconomic cost.
4. The government has an obligation to protect ‘the right to life’. All humans have a right to life as declared in Article 3 of the Universal Declaration of Human Rights (UN, 2015). Simultaneously, as the fact sheet No. 31 states, the governments have “an obligation to adopt appropriate legislative, administrative, budgetary, judicial, promotional and other measures to fully realize the right to health”(WHOd, 2008). Korean government explicitly has a responsibility for people’s suicide since suicide tends to follow the national economic crises. In the financial crisis between 1997/98 and 2008, the rate of suicide dramatically raised, a 6.4% and 5.4% increase respectively (Garg and Kothari, 2018). For this reason, the government needs to protect one’s life from any intruding risks.
Herein are cost-effective interventions which are based off on-going studies.
First, Youth Aware of Mental Health (YAM) is a large-scale mental health promotion study called Saving and Empowering Young Lives in Europe (SEYLE) (Ahern et al., 2018). The target population of YAM is the youth aged 14 to 16 and the program consists of various activities such as reflection, role-play and discussion. The YAM instructors guide the youth to gain their answers instead of giving them the solution to the problem. Several studies evaluated its cost-effectiveness with other interventions; Question, Persuade, Refer (QPR), Screening by Professionals (ProfScreen) (Ahern et al., 2018). The study indicates that YAM is the most cost-effective method among other two methods as for preventing suicide attempts and severe suicidal ideation with a saving cost at €34.83 and €45.42 per 1%-point reduction, respectively, and at €47,017 and €48.216 per QALY gained (Ahern et al., 2018). YAM’s flexibility of engaging in diverse circumstances (e.g. classrooms, peer group, upcoming school events) allows capturing various risks which gatekeepers overlook(Wasserman et al., 2018, Ahern et al., 2018).
Another intervention is a web-based intervention. A study was conducted in the Netherlands, which is a randomized controlled trial of unguided online self-help intervention to adults aged above 18 (van Spijker et al., 2012). Since the intervention is based on cognitive behavioural techniques with web services, it has advantages of easy access and secured anonymity. Plus, it is easy to disseminate the intervention for at-risk people regardless of geographic, psychologic and temporal reasons. Web-based interventions are more effective than the traditional intervention (“face-to-face psychological treatment”), with a saved cost of €5039 (US$5941) per participant per year (van Spijker et al., 2012). Several studies support this online intervention’s cost-effectiveness (Table 2). According to a study conducted in 264 workers, it attributed to gain effectiveness for reducing suicidal thoughts compared to typical treatment (Heber et al., 2013). Intervention using online services is expected to be useful particularly as around 45 million people, 92.4% of the population, use the internet in ROK (IWS, 2017).
Regarding implementing these interventions, there are several barriers.
Firstly, the current financing system in ROK limits to allocate funds on mental health programs and related sectors. Most finance comes from the National Health Promotion Fund, but overall budget plan for suicide is not large (Lee et al., 2017). To secure the budget, the Korea Institute for Health and Social Affairs recommends giving subsidies for preventing suicide alongside sharing local governments’ burdens (Lee et al., 2017). The fact that the Japanese government specifically allocates grants for suicide prevention projects means that there is a high degree of political interest in the projects (Lee et al., 2017). In this sense, the Korean government needs to seek various financing resources for enlarging political interest towards suicide.
Next, the availability of human resources can be a problem(Lee et al., 2017, KDI, 2018) . For performing the intervention targeting on the youth, fostering staffs or professionals who take charge of the intervention is needed simultaneously. However, it is difficult to increase human resources due to a high turnover rate of inexperienced employee (Lee et al., 2017). Thus, it is necessary to secure competent workforce and to improve employment stability in order to upgrade the quality of regional mental health promotion services.
Lastly, implementing the web-based intervention in workplaces cannot completely remove the underlying stressors. With web-based interventions, the work environment should be improved as well. However, this process requires lots of funds, and the rate of participating companies could be low. To alleviate the company’s burden, the Ministry of Employment and Labour or the Ministry of Gender Equality should fund for it through PRP (Performance-related payment) system. Plus, by adopting appropriate certification system, funding or giving incentives to companies engaging in the suicide prevention campaign could motivate their participation.
Suicide is a complicated public health issue due to the combination of social, cultural, physical and psychological factors which manifest one’s psychological pain. However, it is a preventable issue that urgently needs intervention from a governmental level. The biggest problem of ROK’s current plan is that the Ministry of Health and Welfare mainly takes the lead of this issue without simultaneous interventions upon various areas. It is important to invest a lot of money, but it is more necessary to adopt cost-effective strategies that takes advantage of existing infrastructure.
Table 1. Economic evaluation of School-based interventions (Ahern et al., 2018)
|Study||No. of Participants||Mean age in years||Cost categories included||Cost-effectiveness analysis|
|QPR1||2692||14.80||-Training of gatekeepers and facilities
-Cultural adaptation translation of intervention -material
-Printing of intervention material
|Severe suicidal ideation|
|YAM||2721||14.80||-Training of gatekeepers and facilities
-Cultural adaptation translation of intervention material
-Intervention implementation in classrooms
-Printing of intervention material
|Severe suicidal ideation|
|ProfScreen2||2764||14.81||-Training of gatekeepers and facilities
-Cultural adaptation translation of intervention material
|Severe suicidal ideation|
*ICER:€/1% point reduction in incident; #ICER: €/QALY gained
1QPR focuses on training gatekeepers, including teachers, security staff, administrators and so on within schools.
2ProfScreen utilises a self-report system which is constituted by two stages to screen at-risk adolescents.
Table 2. Economic evaluation of Web-based intervention (Donker et al., 2015)
|Author(year/country)||Target||Follow-up time||Cost categories included||Cost-effective analysis (ICER)|
|Hollinghust et al.
|Depression||8months||Intervention costs(therapist costs, overhead charge), healthcare costs, NHS resources, participant costs, productivity costs||£3,528
|Van Spijker et al.
(2012, The Nether-lands)
|Suicide||6weeks||Healthcare costs, participants costs, productivity costs(societal)||€34,727|
|Warmerdam et al.
(2010. The Nether-lands)
|Depression||12weeks||Intervention costs(therapist support, maintenance costs), Healthcare costs, participant costs, productivity costs(societal)||ICBT: ICER=€1,817|
|Hedman et al.
|Direct intervention costs(costs of therapists), healthcare costs, participant costs,
4year follow-up: US$10,100
|Hedman et al.
|Health anxiety||12weeks||Direct intervention costs(costs of therapists), healthcare costs, participant costs,
|Nordgren et al.
|Anxiety||10weeks||Direct intervention costs(costs of therapists), healthcare costs, participant costs,
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