In February 2024, the South Korean government announced a plan to expand medical-school admissions for the first time in nearly two decades, intended to improve a physician-to-population ratio that is one of the lowest among high-income countries. Doctors objected—both to the remedy, which they argued targeted aggregate numbers when the real shortfall lay in particular specialties and regions, and to the manner, which they cast as a quota imposed without their consent—and responded with a nationwide strike. The overwhelming majority of the country's 13,000 trainee doctors walked off the job. For over a year, surgeries were postponed and patients were turned away—even as polls showed a clear majority of the public backing the expansion—until the government rolled the 2026 quota back to its previous level.
In a narrow sense, the profession prevailed—yet the manner of its victory is precisely the point. That such a dispute could only be resolved through a year-long walkout—by sheer disruption rather than by any procedure both sides recognized for settling such questions—indicates that the tacit understanding once governing the sector had already collapsed. A functional arrangement does not require brute enforcement; the strike was not the exercise of an existing pact, but clear evidence of its demise.
This breakdown is not unique to South Korea; the country is less an exception than an early case. Across other health systems, similar tacit agreements are fracturing—each resting on the same understanding: that the profession would be left to govern its own ranks, its numbers included, in exchange for the trust that such self-rule would serve the public good. The flashpoints differ, but the eroding foundation is shared: the implicit rules dictating how these systems operate, and who holds authority over them, no longer hold.
What sustained this arrangement was not law but deference: the profession's knowledge was specialized enough that the public could not readily evaluate it, and so its exercise was largely taken on faith. Never formalized nor opened to public deliberation, the pact held only as long as its legitimacy and efficacy remained unquestioned—its strength was inextricably bound to its fatal flaw, for an arrangement never explicitly settled upon could enforce no accountability.
For decades, this implicit pact sufficed. Today, it no longer does. Countries confronting physician shortages, workforce maldistribution, and difficult choices regarding the volume and placement of doctors can no longer rely on unexamined norms. Unchecked by external mandates, professional self-governance lacks both the incentive and the mechanism to remedy systemic problems that do not directly affect its members—such as the medical vacuums in rural areas. This reflects not the ill will of any particular group, but the structural logic of self-rule without accountability. The present crises force open precisely the critical questions the old settlement kept off the table: who decides, on whose behalf, and toward what ends. The longer they go unanswered, the further marginalized populations are left behind.
While the old paradigm's failure is increasingly evident, a rigorous reckoning with what should replace it has not followed—and the void cannot be filled by reverting to another implicit pact. The pressures ahead only sharpen the need for something more durable: demographic aging, tightening public budgets, and climate-driven health vulnerabilities will impose ever harsher demands, which fragile professional norms, improvised case by case, are ill-equipped to withstand. Yet durability alone is not enough. A new settlement could prove perfectly stable and still illegitimate—a fresh technocracy, as unaccountable as the pact it replaced—because the questions now forced open are not technical problems for experts to optimize and set aside. How many physicians a country requires, and whom they serve, is a value-laden determination of whose health is to count—one no expertise can adjudicate, and no party can settle merely by outlasting a strike. It must be deliberately decided, and the only legitimate means of deciding whom a system is for is to entrust that decision to those it meant to serve.
As foundational trust gives way, the objective is not to penalize or protect any faction within the system, but to transition health-workforce governance into formal, democratic deliberation. This requires transparent, multi-stakeholder mechanisms—ranging from civic committees to legislative oversight—through which the public exercises direct authority over how care is planned and evaluated. Without such reforms, the trajectory of health care will continue to be dictated by professional and political power, at the expense of the most vulnerable. Few systems will be spared the same reckoning. The present collapse is not merely a crisis; it is an overdue opportunity to collectively decide what has for too long been taken for granted.
About the author
Dr Jin-Hwan Kim is a health system researcher based in South Korea, where he has pursued both his medical and academic training. Dr Kim completed his MSc in Health Policy and Management and later earned a PhD in Health Policy at the same institution. His research primarily examines health policy and system evaluation with a strong emphasis on equity and implementation. By drawing on South Korea's experiences, Dr Kim seeks to inform the development of health systems globally. He currently serves as an Assistant Professor at Kyung Hee University College of Medicine. You can find a list of his publications and related scholarly works at his homepage, and request information from him via e-mail.
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