북한이탈주민을 위한 의료지원 연구 : '새조위'의 의료지원 사례를 중심으로 = (A) study on medical services for North Korean refugees : a case study of medical support provided by Saejowi

다국어 초록 (Multilingual Abstract)

To the extent that more than 40% of North Korean defectors leave their jobs or are incapable of engaging in economic activity due to health-related issues, such health-related issues become the largest obstacle to the effectiveness of the South Korean government’s policy of ‘self-reliance, self-support’. In recognizing this relation, the purpose of this research is to examine the necessity of establishing medical support centers for North Korean defectors in order to provide more timely, appropriate treatment when symptoms of physical or psychological pain are reported.
In order to measure this necessity, the following research utilizes data collected over approximately seven years to examine medical support facilities provided by The Organization for One Korea ("TOOK" or "Saejowi"). This research and associated analysis are based upon survey data collected from 400 individuals who received services from treatment centers and medical support centers run by Saejowi to serve the North Korean defector community, medical consultation records of 4,300 individuals, and the results of an in-depth analysis of usage of medical service and support facilities in focus groups consisting of 23-participants. Based upon information obtained through in-person, in-depth interviews with focus group participants, analysis was performed on factors including health condition, use of medical services and support facilities, communication, social, and cultural barriers, difficulties encountered when first using medical services and support facilities, as well as the psychological and social support, capacity strengthening, and community available to overcome such barriers. Furthermore, while classifying responses according to gender, age, time of defection, time of stay in South Korea, health condition, and treatment outcome, medical services and support facilities evaluations based upon medical consultation records were analyzed. Evaluations were focused on communication, accessibility, reliability, and responsiveness.
The results of this research are as follows. First, as North Korea’s national health care system collapsed in the 1990’s, citizens increasingly resorted to self-diagnosis, self-treatment, and other means of informal treatment as opposed to seeking professional services. Second, after defectors enter South Korea, further difficulties are encountered due to problems involving complicated medical procedures and treatment, difficulty communicating with health care providers, and misunderstandings related to treatment. Third, through utilizing the services provided by Saejowi’s medical support centers, communication and social barriers were reduced, and a revitalized sense of psychological and social stability developed while meeting fellow defectors.
In light of these findings, we propose that in order to improve the health of North Korean defectors, the accessibility of medical institutions should be expanded through the provision of medical support environments emphasizing social interaction with patients. Furthermore, barriers to usage of medical service and support facilities must be reduced in order for appropriate and timely treatment to be provided.
The conclusions derived from this research are that after the mid 1990’s the North Korean health care system became largely non-functional, as the inferiority of medical equipment and technology from the 1970’s prevented medical teams at hospitals from practicing medicine, creating structural problems. Consequently, North Koreans increasingly sought treatment from unlicensed practitioners as opposed to utilizing hospital facilities. This behavior is largely explained by the fact that even if an individual decided to seek treatment at a hospital, inadequate facilities and lack of medical supplies made it necessary to not only pay regular hospital fees, but also bribe medical practitioners to make such treatment possible.
Problems even appear in the management of pharmaceuticals. Individuals can purchase pharmaceutical drugs without prescription, and civilians and non-licensed sellers alike produce, buy, and sell drugs. With this information it becomes all the clearer why individuals seeking medical treatment can undergo a deterioration in health level due to drug side-effects and drug abuse. It then becomes evident that North Korean defectors from such an environment are in need of a thorough ‘health education’. The training of professional aides who can provide assistance in administration of drugs and care giving also appears necessary. One possibility is North Korean defector females who are certified as nurses or caregivers.
While a majority of females (55%) and 34% of males are in poor health condition prior to entering South Korea, only 34.5% of females and 21.2% of males report having experience utilizing health treatment facilities before arriving in South Korea. Approximately 37% of men and women alike immediately seek medical advice and assistance when symptoms of pain appear. Amongst these individuals, women’s most common concern regards high medical bills, while men’s worries are more commonly related to illness or disease. Finally, 73% of men and 69% of women report going alone when utilizing medical facilities.
The traumatic memory of life in North Korea, the refugee experience in the transition countries and the accompanying guilt and anxiety, as well as stress from life in South Korea, all contribute to rise in depression and suicide amongst the North Korean refugee population. These factors also seem to explain the rise in incidences of assault and violence amongst North Korean refugees. There is a need to establish ‘a healing and coaching program for North Korean refugees’ to provide mental and psychological support and stability.
A significant portion of both men and women refugees (69.2% and 66.2% respectively) had health problems. Over 50% had more than two distinct health problems, and the most prevalent health issues for men were in stomach (ulcer, gastritis), liver, mental (neuralgia), while it was in stomach (ulcer, gastritis), reproductive system, and orthopedics (spinal) for women.
While a majority of the refugees had high level of trust in South Korean health system (over 80%), a small minority of the refugee population expressed mistrust of the South Korean health system. Out of this group, both genders cited discrimination based on insurance level 1 as a reason for mistrust. Women additionally cited perceived lack of progress from treatment, while men emphasized lack of diagnosis, or being told they were not ill despite pain, as an additional factor.
The most commonly reported difficulties encountered by refugees when using South Korean health care facilities were ‘difficulties in understanding the explanations provided by doctors and nurses’ and ‘difficulties in expressing my opinion to doctors during consultation’, collectively comprising 40% of response. In order of the frequency cited, other common responses regarding problems or concerns related to using South Korean health care facilities included ‘treatment process’, ‘level of trust regarding treatments provided at hospitals’, ‘payment of medically-related fees’, and ‘taking medication or receiving treatment’. Training regarding ‘medical treatment communication strategies’is then necessary for medical practitioners, patients, administrative personnel, and volunteers alike.
As of the time of this research, the population of those receiving services at one of the three medical consultation centers for North Korean refugees (located in Seoul, Daejeon, and Incheon) was comprised of 4,500 first-time users and 3,400 continuing users. The most commonly sought treatments, in order of frequency utilized, were those associated with internal medicine, OB/GYN, orthopedics, neurology, ear-nose-throat (E.N.T.), and neurology. The most frequently utilized departments by in-patients, in order, were internal medicine, neurology, OB/GYN, orthopedics, and surgery. In patients most commonly reported difficulties during their stay included, in order of occurrence, loneliness, concerns related to medical fees, problems regarding care giver, and communication problems with doctors and medical staff.
More than half of refugees that find their way to the medical support centers are introduced to these facilities through the North Korean refugee community. With no relation to gender or age, reported satisfaction level stands at 87.5%. In order of frequency of response cited, the most common reasons for such satisfaction are the kindness of those providing guidance, medical fee assistance, and the fact that such facilities specialize in serving the specific needs of refugees. Reported satisfaction with medical support provided by Saejowi is 86%. Furthermore, 69% of respondents requested that similar facilities serving the North Korean refugee community be established at various locations, and requests for increased efforts to promote awareness of facilities, the provision of general information on health care and education, and the offering of consultations on other issues at medical support centers and hospitals were also common.
Most North Korean refugees report a number of difficulties when utilizing South Korean hospitals and medical care facilities, including complicated treatment processes, difficulties in communicating with doctors and medical staff, and misunderstanding treatment practices unique to South Korea, or at least starkly different from the practices of their native country. However most individuals who have gone to Saejowi medical support centers and received consultations from someone from North Korea report being satisfied with services. This contrast reflects the necessity of providing information about South Korea’s health care system through a means congruent with the expectations of North Korean refugees. Accordingly, it is necessary to foster a more sociable, cordial atmosphere where language that can be understood by the refugees is used, and refugees feel comfortable toask questions and seek help no matter the occasion. It is furthermore imperative that doctors, medical staff, and refugees receive training in ‘medical treatment communication strategies’.
The primary causes of most difficulties experienced by refugees when utilizing South Korean hospitals and medical care facilities include a general unfamiliarity with the medical treatment process, communication with health care professionals, and social prejudices. However, high levels of satisfaction are reported from individuals using medical treatment and consultation facilities for North Korean refugees, as such facilities are regarded as a home-away-from home where individuals can speak freely without fear of being judged. The four central factors contributing to this satisfaction with such facilities can also be identified.
First, the North Korean refugee visitors found counselors who are of North Korean background and the counseling centers’location within the hospital to be helpful in overcoming language and cultural barriers present in the unfamiliar hospital layout and procedures. Second, the visitors also felt comfortable in the counseling center since they could speak freely without divulging their North Korean background and found rapport with those in the center. Third, the key role that North Korean counselors served in the center was seen as an inspiring model of success for the patients. This was particularly true for in-patients. Fourth, the counseling center served as a community center for the visitors. North Korean refugees met friends and neighbors from their respective hometowns and found a supportive community in the center. Some refer to the counseling center as home-away-from home. It can be concluded that the refugees have formed their own community. The benefits of medical support for North Korean refugees have institutional and economic limitations. Thus medical support services that overcome the barriers of language and culture increase the accessibility of medical services and are conducive to improving health outcomes of patients by enabling North Korean patients to seek appropriate care when faced with physical and mental problems.
This thesis is focused on the medical support services provided by Saejowi. Thus, other unconsidered aspects of North Korean medical support services are limitations of the present study. Going forward, the following focus areas need to be considered further to overcome this limitation.
First, a study on the effect of medical support services on the health and economic status of North Korean refugees needs to be conducted. This is critical because the ultimate goal of social and governmental support is to aid North Koreans in their transitions toward becoming a robust citizen in South Korean society. Furthermore, this study can suggest potential ways to minimize the cost of North Korean medical treatments.
Second, an examination of the attitude of South Koreans toward the medical issues of North Korean refugees needs to be done. For robust assimilation of North Korean refugees, prejudices within South Korea society need to be minimal. By accurately assessing South Koreans’ attitude toward North Korean refugees and addressing any issues preemptively, potential conflicts between South Koreans and North Koreans, whose population is expected to rise beyond 100,000, may be prevented.

목차 (Table of Contents)

• 제1장 서 론 = 1
• 제1절 연구배경 및 목적 = 1
• 제2절 선행연구 = 4
• 제3절 연구의 방법 및 구성 = 8
• 제2장 의료지원에 관한 이론적·제도적 배경 = 22
• 제1절 의료서비스 = 22
• 1. 의료서비스 개념 = 22
• 2. 의료서비스 품질 = 23
• 제2절 의료지원에 영향을 미치는 요인 = 26
• 1. 언어·사회문화적 장벽 = 27
• 2. 심리·사회적 지지 = 30
• 3. 역량의 강화 = 33
• 4. 커뮤니티 형성 = 36
• 제3절 남북한 보건의료체계 = 38
• 1. 남북 보건의료체계의 비교 = 39
• 2. 북한 보건의료체계의 특징 = 53
• 제3장 북한이탈주민 의료제도와 문제점 = 63
• 제1절 북한이탈주민 의료지원 = 63
• 1. 입국초기 정부의 의료지원 = 63
• 2. 의료정책 = 67
• 3. 의료보장 제도 = 69
• 제2절 의료지원 이용실태 및 문제점 = 73
• 1. 입국 전·후 건강상태 및 의료이용 실태 = 73
• 2. 의료이용의 문제점 = 102
• 제4장 북한이탈주민 의료지원에 관한 ‘새조위’ 사례 = 114
• 제1절 북한이탈주민 진료센터 = 114
• 1. 진료센터 설립 = 114
• 2. 진료센터의 역할 및 이용현황 = 123
• 제2절 북한이탈주민 의료상담실 및 콜센터 = 124
• 1. 의료상담실 및 콜센터 개소 = 125
• 2. 기능과 역할 = 128
• 제3절 북한이탈주민 의료상담 인력 양성 및 프로그램 = 138
• 1. 전문상담사 양성 배경 및 목적 = 138
• 2. 상담사 역할 = 139
• 3. 전문상담사 양성과정 = 140
• 제4절 새조위 의료지원 이용 평가 = 152
• 1. 의료지원 이용자 수 = 152
• 2. 북한이탈주민 진료센터 이용 경험 = 157
• 3. 의료상담실 이용 평가 = 163
• 4. 상담일지 분석 = 170
• 제5장 결론 = 178
• 참고문헌 = 183
• ABSTRACT = 190
• 부록 = 196