왜 건강불평등인가?

신영전,김명희,Shin, Young-Jeon,Kim, Myoung-Hee 대한예방의학회 2007 예방의학회지 Vol.40 No.6

Objectives : The aim of this study was to introduce the concept of health inequalities, and to discuss the underlying assumptions and ethical backgrounds associated with the issue, as well as the theoretical and practical implications of health inequalities. Methods : Based on a review of the literature, we summarize the concepts of health inequalities and inequities and discuss the underlying assumptions and ethical backgrounds associated with these issues from the view of social justice theory. We then discuss the theoretical and practical implications of health inequalities. Results : Health inequality involves ethical considerations, such as judgments on fairness, and it could provide a sensitive barometer to reflect the fairness of social arrangements. Discussion on health inequalities could deepen our understanding of the social etiology of health and provide a basis for the development of comprehensive and integrative social policies. Conclusions : Health equity is not a social goal in and of itself, but should be considered as a part of a broader effort to seek social justice.

풍진 예방접종사업의 비용-편익분석

신영전,최보율,박항배,문옥륜,윤배중,Shin, Young-Jeon,Choi, Bo-Youl,Park, Hung-Bae,Moon, Ok-Ryun,Yoon, Bae-Joong 대한예방의학회 1994 Journal of Preventive Medicine and Public Health Vol.27 No.2

Rubella is a viral disease with mild constitutional symptoms and generalized rashes. In childhood, it is an inconsequential illness, but when it occurs during early pregnant period, there are significant risks of heart defects, cataract, mental retardation to the fetus. The series of congenital defects induced by rubella is called 'congenital rubella syndrome'. Many research have been performed to find out more effective prevention program on rubella. The objectives of this study are, first, to calculate the incidence rate of acute rubella infection and congenital rubella syndrome in Korea, second, to evaluate economic efficiency of several rubella vaccination policies and to offer data for the most reasonable decision on vaccination policy. Study populations are 663,312 children of one year-old in 1992. The author has performed cost-benefit analyses according to the three vaccination policies-U.S.A.'s. U.K.'s and Sweden's. In this Study, the author got the incidence rate of acute rubella infection using the catalytic model. In the meantime, the author used 50 per 100,000 live births as the incidence rate of congenital rubella syndrome. The discount rate used in this study was 5 percent per annum. The sensitivity analyses were done with different discount rates (4%, 7%) and different incidence rate of congenital rubella syndrome (10,100 per 100,000 live births) : The study results are as follows: 1. Without vaccination, lifetime expenditures per patient for acute rubella infeciton amount to 14,822 won and the total expenditures to about 3.1 billion won. Meanwhile, lifetime expenditures per patient for congenital rubella syndrome amount to about 91 million won and the total expenditures to about 16.3 billion won without vaccination. 2. The cost of vaccination for a child of one year old was 2,322 won and the total cost for the one year old children was about 1.5 billion won (American style). The cost for vaccination of female children at fifteen was about 339 million won (Birtish style). And the cost of vaccination at one for both sex and female children at fifteen was about 1.9 billion won (Swedish style). 3. The benefit to cost ratios of vaccination of female children at fifteen that is the british mode of rubella vaccination, was 60.0 at the level of 80% population coverage and 48.6 at 100% coverage. It shows much higher benefit to cost ratio than those of the other two vaccination policies. 4. Both net benefits of vaccination at one (American style) and that of vaccinations at one and fifteen (Swedish style) range from about 17.0 billion to 17.8 billion won, those were larger than that of vaccinations of female children at fifteen (Birtish style, about 16.0 billion). 5. In marginal cost-benefit analysis of only additional program of revaccination, the benefit to cost ratios were 3.6 (80% coverage rate) or 0.6 (100% coverage rate). It implies that additional program was less efficient or inefficient. 6. In sensitivity analysis with different discount rates(4% or 7%) and different incidence rates of congenital rubella syndrome (10 or 100 per 100,000 live births), the benefit to cost ratios has fluctuated in wide range. However, all the ratios of vaccination of female children at fifteen were higher than those of the others. Even under the most conservative assumption, the benefit to cost ratios of all the rubella vaccination policies were higher than 3.3. In conclusion, all the rubella vaccination policies found to be cost-effective and particularly the vaccination of female children at fifteen was strongly recommended.

보건정책과 사회역학

신영전,Shin, Young-Jeon 대한예방의학회 2005 예방의학회지 Vol.38 No.3

Major approaches of Social epidemiology; 1)holistic, ecological approach, 2)population based approach, 3)development and life-course approach, 4)contextual multi-level approach, have stressed the importance of not only social context of health and illness, but also the population based strategy in the health interventions. Ultimately, it provides the conceptual guidelines and methodological tools to lead toward the healthy public policies; integrated efforts to improve condition which people live: secure, safe, adequate, and sustainable livelihoods, lifestyles, and environments, including housing, education, nutrition, information exchange, child care, transportation, and necessary community and personal social and health services.

글로벌 경제위기와 의료보장의 사각지대

신영전(Young Jeon Shin) 한국사회정책학회 2010 한국사회정책 Vol.17 No.1

최근 글로벌 경제위기는 국민의 건강에도 위협이 되고 있으며 사회안전망으로서 의료보장의 중요성이 커지고 있다. 반면 한국의 의료보장체계는 재정적, 관리적, 정치적 요인으로 인해 8%이상이 의료보장제도에서 배제되고 있고, 보장성 수준 역시 약 60%에 불과하다. 의료비지원 및 긴급지원 사업 역시 복잡하고 분절적인 지원 및 관리방식의 문제, 낮은 보장수준으로 인해 의료사각지대 문제를 충분히 해결하지 못하고 있다. 그 결과 지불능력의10% 이상 의료비를 지출하고 있는 가구규모는 전체 가구수의 10-15%에 이르고 한국 성인의 의료 미충족률이 약 3-10%에 달한다. 이러한 의료보장의 사각지대는 경제위기기에 더 큰 문제를 야기한다. 경제위기기 의료사각지대 문제에 대한 단기적 대응으로 기존의 건강 보험, 의료급여, 의료비지원사업 및 긴급지원 사업간의 상이한 기준, 행정상의 혼선, 늦은 결정 등과 같은 문제들은 강력한 조정기구를 통해 신속하고 상호 유기적으로 작동하도록 하는 것이 필요하다. 중장기적으로는 기존의 의료보장체계를 재구성할 필요가 있다. 의료보장체계를 치료중심에서 예방과 건강증진개념으로 전환하고, 재활과 사회복귀 영역을 추가하며, 여전히 의료사각지대에 있는 사람들을 주요 정책대상에 포함시키며, 민간부문을 통한 재원조달과 서비스 제공 역시 그 틀 안에 포함시킬 필요가 있다. 시민사회와 당사자가 참여하는 운영체계를 구축하고 사업을 지속적으로 모니터링 하는 장치도 만들어야 한다. 그리고 소득, 주거, 교육, 문화부문의 사회안전망과 유기적으로 결합하는 형태로 설계, 운영되어야 한다. 이에 더하여 의료사각지대의 해소문제를 정치의제화하고, 국민건강보험의 획기적 보장성 강화와 제도간 통합이 고려되어야 한다. 아울러 공공보건의료의 양적 확대와 질적 강화를 모색하고 취약계층의 특성에 맞는 사업들을 개발 시행하여야 한다. 경제위기기의 제한된 재정으로 이러한 안전망의 실효성을 유지하기 위해서는 의료비 상승을 유도하는 일련의 정책들을 지양하고 공공성에 기반을 둔 양질의 합리적 의료 공급체계 확보에 우선적인 노력을 기울여야한다. 의료보장 사각지대 해소와 보장성을 높이기 위한 과정은 본질적으로 정치적 과정이다. 따라서 견고한 의료보장체계 구축의 성공은 무한 경쟁과 시장담론을 넘어서는 사회연대의 가치에 대한 담론의 확산, 정치적 리더십, 국민의 지지를 얻을 수 있는 실효성 있는 정책수단의 확보, 안정적인 재원의 마련, 의료보장체계 구축을 위해 헌신하는 정책수립자, 관련 일선 전문가, 시민사회의 역량과 노력에 달려있다. 아울러 견고한 의료보장체계는 경제위기를 극복하는 중요한 기반을 제공할 것이다. With the recent global economic crisis posing a threat to public health, the importance of health security as a social safety net is growing. Bucking the trend, more than 8% of South Koreans are currently excluded from its health-security scheme due to financial, managerial, and political factors, and even the level of health security coverage remains a mere 60%. Moreover, medical-bill assistance and emergency aid projects fail to offer sufficient solutions to the blind spots of health security due to the complicated and segmented assistance provided, managerial issues, and the low level of coverage. As a result, the number of households in South Korea that spends more than 10% of what they can afford to pay on their medical-bills accounts for a remarkable 10-15% of the total number of households, and the South Korean adults` medical insufficiency represents 3-10%. These blind spots of health security pose a bigger threat to the nation under an economic crisis. For short-term measures to address the blind spots of health security under an economic crisis, prompt action is necessary,with the parts working in coordination and with the help of stern arbitration regimes in such problematic areas as the existing medical insurance, healthcare bills, the different standards between medical-bill assistance and emergency aid projects, administrative confusion, and the untimely decision-making process. As for mid-to longer-term measures, the existing health safety net should be restructured. The treatment-centered health safety net should be transformed into the concept of prevention and health enhancement, with the addition of rehabilitation and rejoining the society. Furthermore, the inclusion of those who have been left in the blind spots of the health-security system among the beneficiaries of the major relevant policies is necessary, along with the inclusion of resource procurement and service delivery through the private sector in the said framework. In addition, a mechanism that establishes an operating system where the civil society and the concerned parties can participate in, and that monitors projects in a consistent manner, is required. It should be designed and managed in such a way that it will be in good coordination with the social safety net in the areas of income, housing, education, and culture. In addition, the settlement of the blind spots of the health-security system should be made a matter for political discussion, and consideration must be given to the stark reinforcement of security for the public healthcare system and to the integration of the systems. Moreover, the quantitative expansion and qualitative enhancement of the public health system should be sought through the development and implementation of projects that target the extension of assistance to the underprivileged. In an economic crisis, a series of policies that trigger a rise in medical bills should be sublated while preferentially putting much effort in securing a high quality of reasonable medical-service delivery systems based on publicity to maintain the effectiveness of such safety net. The settlement of the issues regarding the blind spots of the health-security system with enhanced security assumes the nature of a political process. Accordingly, the successful establishment of a firm health safety net lies in the following factors: the expansion of the discussion on the value of social solidarity, which surpasses unlimited competition and market discussion political leaderships securing effective political means with the public supportstable resources policymakers dedicated to the establishment of a medical safety net related working experts on the frontline and the relevant capabilities and efforts of the civil society. A firm health safety net will serve as a critical base in overcoming an economic crisis.

인권의 관점에서 본 한국 고령화 정책 계획

신영전(Young Jeon Shin),김보경(Bo Kyoung Kim) 한국사회정책학회 2013 한국사회정책 Vol.20 No.1

이 연구는 한국 정부의 고령화 정책이 『마드리드 고령화행동계획』이 요구하는 노인인권의 측면을 잘 반영하고 있는지 확인함으로써 인권친화적인 고령화 정책의 수립을 위한 정책 과 제를 제시하는 것을 목적으로 시행하였다. 이를 위해 『제2차 저출산고령사회 기본계획』(이 하 『기본계획』)의 수립과정에 대하여 인권적 요소를 평가하였고, 『기본계획』, 『2011 중앙부 처 시행계획』 및 『2011 서울시 시행계획』의 내용에 대하여 『마드리드 고령화행동계획』(이 하 MIPAA)의 35개 행동목표와의 정합성 여부를 확인하였다. 분석결과, 기본계획의 수립과 정에서 참여와 투명성이 부분적으로 확인되었으나 인권적 측면에서 충분하지 못하였다. MIPAA와의 정합성 평가 결과, 한국 고령화 정책은 MIPAA가 제안하고 있는 인권적 요소를 상당부분 반영하고 있으나 노인의 의사결정 참여, 여성 · 장애 · 농촌노인 등 취약집단에 대 한 정책과 관련한 일부 영역에서 충분하지 못함을 확인하였다. 향후 고령화 정책의 수립과정 과 계획 작성에 노인인권을 보다 적극적으로 반영하기 위해 기존 계획에서 누락된 영역의 노 인인권정책을 보완할 필요가 있다. 특별히 노인인권 옹호를 위한 담론 개발, 인권영향평가 도 입, 노인인권 모니터링을 위한 지표 개발, 인권기반 고령화 정책 수립과 집행을 위한 지침 제 공, 취약한 노인 집단에 대한 집중 등이 필요하다. 또한 인권 친화적 고령화 정책을 수립 시행 시에는 기본계획과 시행계획 정책 간의 연계를 강화하면서 보다 인권 친화적 과정이 되도록 제도화가 필요하다. The purpose of this study is to examine how the government`s ageing population policies embrace the human rights of older persons to set out policy agenda for the establishment of ageing population policies that help protect human rights. First, the human rights elements in the establishment of 『The 2nd Plan for Ageing Society and Population』(hereinafter the “Basic Plan”) were examined. Second, 『Basic Plan』, 『2011 Central Government Execution Plan』 and 『2011 Seoul City Execution Plan』were reviewed to find out whether they conform to the 35 objectives of『Madrid International Plan of Action on Ageing』(MIPAA). The analysis produced results that participation and transparency assurance mechanisms were identified in the establishment of basic plan but the human rights elements were found out to be insufficient or difficult to verify. The conformity test in comparison with MIPAA, Korea`s ageing population policies turned out to reflect a large portion of human rights elements provided by MIPAA but fail to sufficiently embrace the policies with regard to older persons` participation in decision-making processes and the underprivileged groups such as older women, older persons with disabilities, and older persons in rural areas. Older persons` human rights policies must be upgraded to close loopholes in the existing plans in order to embrace the human rights of the elderly more actively in the establishment and planning of ageing population policies. Furthermore, more efforts are required to develop agenda for the protection of senior human rights, introduce human rights impact assessment, establish guidelines over the establishment and execution of human rights-based ageing population policies, and concentrate resources on underprivileged older population. For the establishment and execution of human rights-based ageing population policies, the basic and execution plans must be associated with each other to assure the systematization of human rights-based processes.

사회권으로서의 건강권

신영전(Shin Young Jeon) 비판과 대안을 위한 사회복지학회 2011 비판사회정책 Vol.- No.32

그간 상대적으로 논의가 적었던 사회권으로서의 건강권의 내용을 구체적으로 파악하고 사회권 규약의 실효성을 높이기 위하여 사회권으로서의 건강권 관련 지표들의 도출가능성을 검토하였다. 이를 위해 기존 관련 지표를 참조하여 사회권적 건강권 지표들을 선택하고 그 지표에 따른 한국 사회의 사회권적 건강권의 현황을 파악하고 그 정책적 함의를 살펴보았다. 국내외 건강권 관련 선언, 규약, 법률 등에서 규정하고 있는 건강권 중에서 사회권적 성격을 강하게 가지는 건강권은 ‘모든 사람이 도달 가능한 최고 수준의 신체적, 정신적 건강을 향유하는 데 필요한 최선의 보건 의료서비스를 제공받을 권리’와 ‘안전한 작업, 생활 환경을 보장받을 권리’였다. 한국 사회에서 사회권적 성격을 가지는 건강권은 제도적 형태는 갖추었으나 내용적으로는 OECD 국가 평균에 비해 부족한 것으로 나타났다. 특별히 낮은 의료보장 수준, 높은 의료사각지대, 낮은 국민의료비 중 공공의료비 비중, 높은 산업 재해율 등의 문제가 심각한 것으로 나타났다. 일부 지표는 체계적인 수집이 이루어지지 않고 있었다. 건강 지표에서도 한국 남성의 출생시 기대수명, 결핵 유병률, 잠재수명손실년수(potential years of life lost, PYLL)로 측정되는 조기사망률, 저체중아출생률, 자가보고 건강수준도 OECD 국가의 평균보다 나쁜 것으로 나타났다. 향후 지표의 타당도와 신뢰도 및 국제적 비교가능성을 높이기 위한 추가적인 작업과 함께 이들 지표의 실효화를 통해 사회권적 성격을 가지는 건강권의 향상에 기여하도록 하는 작업이 필요하다. We investigated the details of health rights as social rights and developed their indicators. We then explored their applicability in promoting the health rights as social rights. From the previously developed indicators, we selected relevant indicators and checked the condition of health rights as social rights in the Republic of Korea (hereafter South Korea) using the indicators. We also discuss the policy implications of our results. From the various forms of manifestos, agreements, laws, and bills related to human rights, we summarized two components of health rights as social rights: the right to health care services for the highest attainable standard of health services for all and the right to safe and healthy working and living conditions. Health rights as social rights in South Korea are well institutionalized. They do not, however, worked sufficiently as in the average OECD country: South Korea has a low coverage rate for health insurance, a large population not covered by health insurance, a low level of public share of total expenditure on health, and the highest rate of fatal work injuries. Several indicators do not have official statistics. Related to health outcome, men’s life expectancy at birth, the prevalence of tuberculosis, an early death rate measured by potential years of life lost(PYLL), a low birth weight, and perceived health status are poorer than those of the OECD countries. Further research to improve reliability, validity, and international compatibility, and activities to promote health rights as social rights through realizing the indicators in practice are needed.

‘의료민영화’정책과 이에 대한 사회적 대응의 역사적 맥락과 전개

신영전(Shin Young Jeon) 비판과 대안을 위한 사회복지학회 2010 비판사회정책 Vol.- No.29

참여정부와 이명박 정부로 이어지는 ‘의료민영화’ 정책은 보건의료체계의 큰 변화를 야기하고 있다. 그간 공적이라고 간주되어오던 보건의료서비스 부문에 ‘영리성’을 공식화하고‘탈보건의료 정책화’경향이 강화되고 있다. 또한 의료민영화를 둘러싼 사회적 갈등이 커지고 있다. 작금에 한국 보건의료체계 내에서 보이고 있는 갈등의 핵심인 ‘공공성’과 ‘시장 또는 영리’의 충돌은 역사성을 가진다. 해방 직후 한반도 남쪽에 구축된 보건의료체계는 일제잔재의 존속, 급진적 이상의 배제, 미국식 제도의 이식, 그리고‘밖으로부터’의 강제라는 매우 ‘기형적인’ 형태로 탄생하였으며 현재 갈등 상황의 단초를 제공하였다. 개발독재시기 보건의료정책이 경제개발이나 정치적 정당화 논리에 귀속되는 상황 속에서 공공보건의료체계에 대한 지원은 최소화되었다. 그리고 정부-공급자간의‘암묵적 담합구조’는 한국의 보건의료체계의 비합리성을 강화하였다. 이러한 토대 위에서 1997년 경제위기를 맞은 한국사회는 신자유주의의 영향력 하에 놓이게 되었으며, 의료민영화는 1997년 체제의 토대 위에서 탄생하였다. 최근 이명박 정부 하에서 친시장적 세력이 입법부와 행정부를 장악하게 됨에 따라 의료민영화의 본격적인 추진이 이루어지고 있다. 그러나 전통적으로 보건의료의 공공성을 지지해 왔던 시민, 노동세력들이 이에 저항하고 있다. 현재 추진되고 있는 의료민영화정책은 1) 국민의 건강증진보다는 민간보험회사로 대변되는 대자본의 이익을 우선시 하는 방식으로 설계되어 추진되고 있다. 반면 소자본 의료공급자, 사회경제적 소외 지역이나 집단에 대한 이해에 충분히 부응하고 있지 못하다. 2) 정책의 수립과 추진과정에서 관련 이해관계자들의 참여가 이루어지지 않고 있다. 3) 의료민영화로 인해 예상되는 폐해에 대한 대비가 제시되지 않고 있다. 4) 정부가 제시하는 자료들의 과학적 근거들은 불명확하다. 따라서 향후 정책의 득실과 부작용에 대한 과학적 평가와 적절한 대처, 정책적 논의공간과 국민적 합의과정 마련 등을 통해 민주적 공공성을 확보하는 것이 필요하다. Health care system in Korea is showing a divisive aspect and at the heart of the development is the health care privatization policy. Confusions revolving around the policy have evolved primarily from the conflict between ‘Publicness’ that has represented an ‘official’ ideology of the health care system in Korea and the other principle upheld by ‘Market or Profit’ that has recently gained legality in the field of health care services. The conflict between ‘Publicness’ and ‘Market or Profit’ that represents the bottom line of confusion within health care system has historical context. The health care system in the southern half of the Korean Peninsula took on a highly ‘abnormal’ format that blended the remnants of the Japanese rule, exclusion of radical ideals, transplantation of American institutions and compulsion ‘from outside’, creating the origin of the ‘divisive’ landscape of today. During the era of dictatorial rule, cases for economic development or political legitimation prevailed over health care policies, minimizing support for the public health care system. And the ‘tacit collusion’ between the government and the health care providers strengthened the irrationality of health care system in Korea. Against the backdrop, Korean society that fell victim to the financial crisis in 1997 succumbed to the influence of neo-liberalism and health care privatization was born on the base of the 1997 regime. As pro-market forces have dominated the executive and the legislative bodies in the Lee Myung-Bak administration, momentum is building up to pave the way for health care privatization to proceed in earnest. However, civil rights activists and trade unions that have advocated the publicness of healthcare service traditionally are protesting against such move. The health care privatization policy that the government is pushing for now 1) leans toward the interests of capital that private health insurers represent rather than promotion of health for the general public, failing to accommodate the interests of small healthcare service providers, socioeconomically-underprivileged regions or groups. 2) Stakeholders are not engaged in the policy making and implementation processes. 3) Anticipated dysfunctions of health care privatization are not indicated. 4) Scientific cases for the data presented by the government are unclear. Therefore, it is necessary to ensure democratic and public values subsequently by evaluating pros and cons of the policy scientifically, developing proper countermeasures and creating a process by which policy issues are discussed and public consensus is built.

최응석의 생애

신영전(SHIN Young-joen),김진혁(KIM Jinhyouk) 대한의사학회 2014 醫史學 Vol.23 No.3

건강형평정책과 사업

신영전(Young Jeon Shin),윤태호(Tae Ho Yoon),김명희(Myoung Hee Kim),정백근(Baek Geun Jeong),서제희(Jae Hee Seo) 한국사회정책학회 2011 한국사회정책 Vol.18 No.4

최근 건강 수준이 전반적으로 향상되었음에도 불구하고, 건강 불평등 문제는 점차 심각해지고 있어 건강형평이 중요한 보건정책 과제로 부각되고 있다. 건강 불평등의 완화를 위한 노력의 중요성에도 불구하고 아직 한국 내에서는 건강 불평등 완화를 위한 필요성, 주요 접근원칙과 접근 방법에 대한 논의는 지극히 초기 단계에 머물러 있다. 건강형평정책은 건강 불평등의 예방과 완화, 해소를 위해 행해지는 모든 정책 또는 사업을 의미하며, 이것은 규범적인 측면에서 뿐만 아니라 현실적, 실용적 측면에도 필요하다. 기존의 보건사업 방식만으로는 건강 불평등을 예방, 완화, 해소하기 어려우므로 1) 건강공공정책과 부문 간 협력, 2) 다수준적 접근, 3) 지역기반전략, 4) 생애적 접근, 5) 참여, 역량 강화, 맥락에 대한 고려, 6) 건강 불평등 해소를 위한 모니터링, 관리와 평가와 같은 접근이 필요하다. 향후 건강형평관련 정책/사업과 연구가 지속적으로 이루어져야 하며, 정책/사업의 기획과 시행에는 국내외 경험과 연구결과들을 바탕으로 만들어진 주요 원칙 및 접근방법을 유용하게 활용하여야 할 것이다. Despite overall health improvement over a few decades, health inequalities seem to be worsening, which calls for alternative health policies to consider health equity as their major agenda. However, yet much has been not discussed over justification of alleviating health inequalities, principles in program/policy planning, and modalities for delivery. Health equity policies are defined as all policies and programs to be implemented for preventing, alleviating and eliminating health inequalities. They are required for practical as well as normative reasons. Conventional health programs solely cannot tackle health inequalities and the followings are required; 1) healthy public policies and inter-sectoral cooperation; 2) multi-level approach; 3) area-based strategies; 4) life-course approach; 5) consideration for participation, empowerment, and social contexts; 6) monitoring, management, and evaluation of policies and programs through an equity lense. Further research and policy/programs for health equity should be followed in Korea. In addition, key principles and appropriate approach based on the best available evidence should be applied in planning and implementing policies and programs.

의료이용의 지역간 격차 -3차성 내과계 진단군을 중심으로-

신영전 ( Young Jeon Shin ),이원영 ( Weon Young Lee ),문옥륜 ( Ok Ryun Moon ) 한국보건행정학회 1999 보건행정학회지 Vol.9 No.1