Changing the Care Process: A New Concept in Iranian Rural Health Care

Abbas Abbaszadeh,Manijeh Eskandari,Fariba Borhani 한국간호과학회 2013 Asian Nursing Research Vol.7 No.1

Purpose: Health care delivery systems in rural areas face numerous challenges in meeting the community’s needs. There is a lack of adequate attention for this problem. This study aims to explore the challenges of the health care process in rural Iran according to health care providers’ experiences. Methods: This was a qualitative study that used the content analysis method. We selected a total of 21 health care providers based on purposive sampling. Data collection consisted of semi-structured individual interviews that were analyzed by qualitative content analysis. Results: Data analysis led to the formation of one main category, the challenges of process of health care in rural society. Within this main category, we created the following subcategories: change in characteristics of the rural society, increase in complexity of the health care process, decrease in workforce efficiency, and decrease in propensity of people’s care. Conclusion: The findings of this study indicate that the process of health care in Iranian rural society is changing rapidly with community health workers encountering new challenges. There is diminished efficiency in responding to the changing care process in Iran’s rural society. Considering this change in process of care, therefore, the health care system should respond to these new challenges by establishing new health care models. Purpose: Health care delivery systems in rural areas face numerous challenges in meeting the community’s needs. There is a lack of adequate attention for this problem. This study aims to explore the challenges of the health care process in rural Iran according to health care providers’ experiences. Methods: This was a qualitative study that used the content analysis method. We selected a total of 21 health care providers based on purposive sampling. Data collection consisted of semi-structured individual interviews that were analyzed by qualitative content analysis. Results: Data analysis led to the formation of one main category, the challenges of process of health care in rural society. Within this main category, we created the following subcategories: change in characteristics of the rural society, increase in complexity of the health care process, decrease in workforce efficiency, and decrease in propensity of people’s care. Conclusion: The findings of this study indicate that the process of health care in Iranian rural society is changing rapidly with community health workers encountering new challenges. There is diminished efficiency in responding to the changing care process in Iran’s rural society. Considering this change in process of care, therefore, the health care system should respond to these new challenges by establishing new health care models.

의료 서비스에 대한 만족도 측정 도구의 개발 : focused on Patients and their families

강소영,이선미 한국의료QA학회 1996 한국의료질향상학회지 Vol.3 No.1

Background : In these days, the health care organizations have concerned about customer-centered care in order to empower the competitiveness on the health care markets. The departments working for quality management of the hospitals have used health care quality indicators in terms of medical areas as well as service areas of the hospitals. However, there were insufficient efforts to develop the credible measurement t seek the customers' needs, their expectations and their satisfaction levels related to health care services because various kinds of challenges were in the process of scale development to measure customers' satisfaction in health care. The purpose of this study was to develop the satisfaction scale to health care services in a Korea health care organization and to test its tool with validity and reliability. Method : The concept of this tool was acceptability that is one of the components of health care quality defined by Donabedian. Acceptability has the five dimensions of concept : Accessibility; Patient-Practitioner Relations; Amenities; Patient Preferences as to the effects of care; and Patient Preferences as to the costs of care. The Satisfaction Tool to Health Care Services was reviewed by expert panel with five researchers, including hospital managers and a professor related to quality management of the hospitals. As a result, the content validity index was 84 in the outpatient satisfaction tool. The inpatient satisfaction tool had 87 of the content validity indes. The Satisfaction Tools to Health Care Services finally consisted of 44 items for outpatients/their families and of 60 items for inpatients/their families. Study subjects of the construct validity test were 479 outpatients/their families and 561 inpatients/their families who visited or admitted at a University hospital from July 1, 1996 through August 10, 1996. The data were examined by Factor Analysis with SPSS. Result : The items of the Satisfaction tools for outpatients/their families were categorized by eleven factors with eigenvalue greater than 1.0 accounting for 64.2 percent of the variation in item scores. Also, the items of inpatient tool had eleven factors with eigenvalue greater than 1.0 accounting for 60.3 percent of the variation in item scores. The reliability of overall scale were .95 and .96 for the outpatients/their families satisfaction scores and the inpatient/their families satisfaction scores. The internal consistency reliability with eleven factors was ranged from .30 to .94 for inpatients/their families. The Satisfaction Tool with eleven factors for inpatients/their families had internal consistency reliability ranged from 053 to .89. Conclusion : The Satisfaction Tools to Health Care Services focused on outpatients/their families and inpatients/their families developed in this study had a high reliability and the strong evidence of content validity and construct validity based on quality concept. Therefore, this tool would be utilized as a credible quality indicator of health care services to assess the quality problems and to monitor to quality improvement activities in Korean Health Care Organizations.

대형 종합병원(3차기관)의 진료실적 및 환자의 지역분포에 관한 연구

이윤현 中央醫學社 1992 中央醫學 Vol.57 No.6

Virtually the whole population is covered by medical care under social security in Korea as of July 1, 1989. The health care system has been undergoing rapid change, and face rising costs through the problems posed by rising expectations on the part of consumers and providers and increasing demands for the quality care. In particular, to cope with the expansion in the volume of claims in tertiary care hospital, government has introduced Health Care Delivery System. This new system pohibited insured persons from random use of health facilities. They were not allowed to use secondary or tertiary medical facilities without the approval of primary care physicans. The main aim of the present study is to review status quo of the current health care delivery system, analyze the problems and the recommendations base on efficiency and equity concept through eight health care regions. First, the level of inpatients days per claim increased 13.4 days in 1990 to 13.8 days in 1991 in the medical treatment of tertiary care hospital, and from 1.6 days to 1.7 days in the outpatient volume. Second, the whole nation was regionalized into the Eight Health Service Regions. If patients want to see a specialist in the other Health Service Regions, they should get a permit from their insurance society as well as a primary care physician's referal request. This, however, raised a serious problem of equity between the Metropolitan Erea and the others. The problem of inequity has been caused by the ubiquity of health resources among health services regions. Third, the major barrier to equiable access to the health care system is the lack of a regular health resources in each health service regions. The government should make a decision to adopt the regulated system of health care delivery as the impartial sharing of health resources.

의료생활협동조합 의원의 일차의료서비스 질 평가

최윤구,김경우,최용준,성낙진,김재용,박진하,홍승권,이재호,일차의료연구회 대한가정의학회 2010 Korean Journal of Family Medicine Vol.31 No.10

Background: In South Korea, major health care problems have been occurred under the structural background that medical services are mainly provided by private medical institutions. Primary health care, which is very crucial in public health, has been overlooked, and is disorganized and fragmented. In the mean time, health cooperative movement was initiated by local residents and medical doctors to overcome health care problems in 1987. We conducted this study to evaluate the role of health cooperative clinics and obtain lessons for the future primary care policy. Methods: During April to June in 2006, survey was performed by a trained interviewer at the waiting rooms of 3 health cooperative clinics, in the process of development of the Korean Primary Care Assessment Tool (KPCAT). The KPCAT consists of 5 domains (21 items): first contact (5), coordination function (3), comprehensiveness (4), family/community orientation (4), and personalized care (5). Subjects were patients (or guardians) who had visited their health cooperative clinics on six or more occasions over a period of more than 6 months. We compared primary care scores of each domain between members and non-members of health cooperative clinics by student t-test. Effect of having a membership on each primary care domains was examined by multiple regression analysis. Results: Among the participants (N = 100), members of health cooperatives were 48, and non-members 52. Total average scores of 5 primary care domains of the KPCAT were 78.0 ± 13.5 on 100 point scale. (82.0 ± 13.1 in members, and 74.3± 13.0 in nonmembers; P = 0.004) Among primary care domains, personalized care was the highest (91.4 ± 11.0), and coordination function the lowest (61.0 ± 33.1) in score. Significant differences between members and nonmembers were noted in coordination function (68.9 vs. 53.7, P = 0.021) and comprehensiveness (78.4 vs. 67.2, P = 0.008). These differences were continued after adjusting by multiple regression analysis for socio-demographic variables including age,sex, income, education, number of disease, and duration since the first visit. Conclusion: In the health cooperative clinics whose primary care performance has been considered exemplary in the context of health care in South Korea, primary care scores assessed by members were higher than those by non-members. The significant differences of scores in coordination function and comprehensiveness between members and nonmembers suggest that the future primary care policy should be focused to strengthen these two domains of primary care. 연구배경: 우리나라 보건의료체계는 의료기관의 사적소유가지배적이며 공공성이 결여되어 있는 문제를 안고 있다. 국민건강증진과 질병예방에 기여하는 일차보건의료는 간과되어왔고, 조직화되어 있지 못하고 분절화되어 제공되고 있다. 이러한 보건의료 문제 상황을 극복하기 위하여 지역 주민과 의료인이 함께 운영하는 의료생활협동조합(의료생협) 운동이시작(1987)되었다. 의료생협은 일차의료의 바람직한 대안으로 평가되기도 한다. 본 연구는 의료생협이 수행하는 일차의료기관으로서의 역할에 대해 평가하여 향후 일차의료 정책을위한 교훈을 얻고자 시행하였다. 방법: 한국 일차의료 평가 도구(the Korean Primary Care Assessment Tool, KPCAT) 개발을 위하여 2006년 4월부터 6월까지 수집된 자료 중에서, 인천시, 안산시, 안성시에 위치한 의료생협세 곳의 자료를 분석하였다. 의료생협을 상용치료원으로 이용하는(방문한 지 6개월이 경과하고 6회 이상 방문한) 환자또는 보호자가 평가 주체로 참여하였다. KPCAT의 5개 영역즉, 최초 접촉, 포괄성, 조정 기능, 전인적 의료, 가족/지역사회지향성에 대해서, 영역별 점수를 구하고 의료생협 조합원 여부에 따라 영역별 점수를 비교하였으며, 인구사회학적인 변수를 통제한 후의 변화를 관찰하였다. 통계분석을 위해, 영역별 점수비교에는 t-검정을, 그리고 인구사회학적 변수의 통제에는 다중회귀분석을 이용하였다. 결과: 의료생협을 상용치료원으로 이용하는 지역주민 100명이 본 연구에 참여하였다. 의료생협 조합원은 48명, 비조합원은 52명이었다. KPCAT 일차의료 속성영역 5개 평균점수를 100점 척도로 나타내었을 때, 의료생협의원의 일차의료평균점수는 78.0±13.5 (조합원 82.0±13.1, 비조합원 74.3±13.0;P=0.004)이었다. 일차의료 영역들 중에서 점수가 높은 것은 전인적 의료(91.4±11.0), 최초접촉(89.3±11.5)이었으며, 점수가낮은 것은 조정기능(61.0±33.1), 포괄성(72.6±21.4)이었다. 조합원 여부에 따라 유의한 차이를 보인 영역은 조정기능(68.9vs. 53.7, P=0.021)과 포괄성(78.4 vs. 67.2, P=0.008)이었다. 이 같은 차이는 연령, 성, 소득, 교육수준, 질병의 수, 첫 방문 후 경과기간 등의 변수를 다중회귀분석으로 통제한 후에도 지속되었다. 결론: 우리나라 보건의료 맥락에서 모범적인 일차의료기관으로 평가되는 의료생협의원에서, 주치의 서비스를 받는 조합원이 평가한 의료생협의 일차의료서비스 질은 기존 방식의진료를 받는 비조합원이 평가 한 것보다 우수하였다. 특히 조정기능과 포괄성 영역에서의 유의한 차이가 있는 점은, 향후주치의제도 도입 등 일차의료 정책 수립 시에, 일차의료의 조정기능과 포괄성 영역을 강화시키는 데 역점을 두어야 한다는 점을 시사한다.

윤석열 정부의 보건의료정책 방향과 과제

박은철,Park, Eun-Cheol 한국보건행정학회 2022 보건행정학회지 Vol.32 No.3

The presidential election and the inauguration of the new government are a period of the policy window opening. The newly launched government is expected to improve the quality of life of the people. The Yoon Suk-yeol Government is also launched with new expectations with a transitional period in health care. The sustainability of health care in Korea is threatened. The environment of health care and the main policy issues of health care are difficult to secure the necessary finance for health care in spite of the increasing health care burden. Accordingly, the Yoon Suk-yeol Government's health care policy aims to provide intensive support to those in need of health and welfare and to improve the health of the people through investment in health. And for integrating fragmented health care and welfare services and creating people-centered community-based health care, a health care innovation center will be established for the evaluation platform of new delivery and payment systems, a health care development plan will be established for the blueprint of health care, and reorganizing the central & local government should be reviewed. Although we are facing unfavorable situations such as the distribution of the National Assembly, inflation, and the possibility of economic recession, we expect that announced health care policies will be implemented, recognizing that health care innovation is the only way to improve health care sustainability.

Psychosocially Supportive Design : Scandinavian Health Care Design

Alan Dilani, PhD,변혜령(역) 한국병원건축학회 2000 심포지엄 Vol.2000 No.1

본 글에서는 현대의 의료시설 디자인에서 강조되고 있는 기본 개념과 기준들에 대해서 논의해보고자 한다. 생물의학분야에서는 질병의 병원(病原) 개념에 주력하다가 최근에는 salutogenic 관점에 그 관심을 돌리고 있다. 이러한 변화는 건물 디자인과 치료철학(care philosophy)을 더욱 밀접하게 하였을 뿐만 아니라 의료서비스의 질을 향상시켰으며 건강관리과정(health processes)을 개선하고 강화시켰다. 전통적으로, 병원론적 관점에서는 대개 환자를 대상물로 간주하며 인체의 "병든 부분들"각각에 관심을 집중시키고 있으며, 이러한 경향은 인체를 더욱 세부적 부분들로 분할하고 그 각각을 따로 분리하여 치료하였다. 또한, 이러한 관점에서 의료시설은 치료를 받은 신체 부분의 물리적 요구를 만족시켜 주는 의료기술환경(medical-technical environment)으로 해석되어 왔다. 이것은 의료시설은 질병에 노출되는 위험성을 최소화 시켜야 한다는 점을 중요하게 간주하고 있다. 비교적 적은 수의 병원에서는 아주 시설적인 치료환경과 외상병원(traumatic hospital)이었음에도 불구하고 환자들을 안정시키고 긴장을 풀 수 있도록 해주고 있다. 병원론적 관점으로 인해 환자의 심리적, 사회적, 정신적 요구들이 의료시설의 디자인에 전혀 반영되지 못하였으며, 치료철학에서 무시되어 왔다. 질병 및 건강에 대한 병원론적 개념과 함께 기능적 효율성이 강조됨으로써 의료시설은 사회 심리적인 지원성을 갖추지 못한 환경이 되고 말았다. 하지만, 최근 들어 새로운 패러다임을 이끌어낼 다른 견해가 부각되고 있다 현대 의학은 질병의 개념을 더 이상 협의의 병원론만으로 해석하지 않고 대신에 질병은 다각적인 면을 보유하고 있으며 다양한 원인과 요소들로 이루어진 것으로 간주하기 시작하였다. 건강을 증진시키는 과정에 중점을 두고 있는 salutogenic 관점이 치료철학에서 뿐만 아니라 새로운 의료시설을 만드는데 중요하게 고려되고 있다. 새로운 패러다임에서 초점을 맞추고 있는 것은 바로 환자이다. 즉, 환자의 육체적 건강과 관련된 요구뿐만 아니라 그들의 심리적, 사회적, 건강과 관련된 요구들도 치료활동에서, 그리고 병원환경의 디자인에서 매우 중요하게 간주되고 있다. 새천년을 맞이하여 우리는 병원론적 관점, 기능주의, 건축의 표준화와 합리화라는 개념에서 벗어나야 할 것이다. 계획가들은 회복(wellness)을 양성하는 디자인 기준을 개발해야 한다. 잘 디자인된 물리적 환경은 회복을 이끌어낼 수 있지만 반대로 나쁜 디자인은 사람들을 좌절시키고 병들게 만들 수 있다. 우리는 사회심리적으로 지원성을 가지고 있으며 건강을 향상시킬 수 있는 물리적 환경을 조성해야 한다. 더 넓은 개념의 건강에 초점을 두고 있는 치료철학을 개발하고 사회 심리적인 지원성을 지닌 디자인의 역할을 널리 알릴 필요가 있다. The purpose of this paper is to discuss the basic ideas and criteria underlying contemporary health facility design. Special attention is given to the growing shift in the biomedical attitude from a largely pathogenic concept of disease to a more salutogenic perspective. This shift should not only lead to a stronger integration of building design and care philosophy but also result in an enhanced quality of medical care and in improved and strengthened health processes. Traditionally, the pathogenic perspective has tended to consider patients as objects and concentrated on individual "sick parts" of the human body, which were further and further divided into smaller parts and separately treated. Consistent with this perspective, Health care facilities have been interpreted as medical-technical environments oriented toward the physical needs of the treated body part. From this perspective the main requirement placed on Health care facilities has often been interpreted narrowly as the reduction of the risk of exposure to disease. Comparatively little priority has been given to calming the patients and making them feel relaxed in spite of traumatic hospital experiences and starkly institutional care environments. Other consequences of the pathogenic perspective have been that psychological, social and spiritual needs of patients have been largely disregarded in the design of Health care facilities, and often marginalized in the philosophy of delivering care. The emphasis on functional efficiency, together with the pathogenic conception of disease and health, has often produced Health care facilities that are not psychosocially supportive. In recent years, however, a different perspective has emerged leading to a new paradigm. The modern disease concept is no longer narrowly pathogenic; rather, disease is seen as multifaceted and having a variety of causes or elements. The salutogenic perspective, which focuses on Health promoting processes, has become much more central to the consideration of care philosophies and in the creation of new Health care facilities. In the new paradigm, the focus is on the patients: along with their physical health needs the patients' psychological and social health needs are given major emphasis in the delivery of care activities and in the design of Health care environments. In the new millennium we will take a step away from the pathogenic perspective, functionalist, standardization and rationalization of building production. The term wellness factor should inspire planners to develop design criteria that foster wellness. Well-designed physical environments tend to foster wellness whereas poor design tends to frustrate people and thereby foster illness. We need to create physical environments that are psychosocially supportive and, thereby, can enhance health processes. There is a need to develop care philosophies that focus on a broader concept of health, thus fostering greater awareness of the role of psychosocially supportive design.

독일의 디지털 헬스케어 법제

김수정 이화여자대학교 법학연구소 2022 法學論集 Vol.27 No.1

German Digital Health Care Act was enacted to introduce and supplement electronic prescriptions in the fields of home treatment, outpatient intensive care, social therapy, therapeutics and auxiliary devices, anesthetics and other prescription drugs. The Act includes a series of Acts which revise German Health Care System including German Social Code V. The Patient Data Protection Act (PDSG) stipulates the patient’s control over electronic patient records and the doctor’s responsibility. The Digital Health Care Act (DVG) and the Digital Health Care and Care Modernization Act (DVPMG) defines the details of digital Apps to assist with treatment. The PDSG provides that e-prescriptions in statutory health care must be used for the prescription of prescription drugs. Patients are able to call up the e-prescription information on their smartphone using an App which are part of the secure telematics infrastructure or to retrieve the e-prescription as a printout on paper. Patients have the right to have doctors fill in e-patient file. In addition to findings, medical reports or X-rays, the vaccination card, the maternity card can be saved in the electronic patient files. Doctors and hospitals who make entries in an e-patient file for the first time receive 10 euros for this. Doctors, dentists and pharmacists also receive remuneration for supporting the insured in the further administration of their e-patient file. Insured persons can have their data transferred from the ePA when changing health insurance and will have the option of making the data stored in the ePA available to medical research voluntarily and in compliance with data protection regulations. The Digital Supply and Care Modernization Act creates systems for digital health Apps (DiGA) and digital care Apps(DiPA). DiGA can be prescribed by doctors or psychotherapists after Approval by the health insurance company. The prerequisite is that the Applications have previously passed a test for requirements such as security, functionality, data protection and data security. DiPA is expected to support those in need of care and their relatives to better manage and organize their everyday caregiving. They can also improve communication and interaction with caregivers. Because health-related information is digitized and made available for distribution, the risk of unauthorized access to personal information by others will increase definitely. In legislating e-prescription App, e-patient file, health and care Apps, personal information protection was an important issue in the legislative process. In addition, German legislators prepare various systems so that the foundation for digital health care can be operated technically safely, and health insurance or nursing care insurance pays a portion of the costs incurred by digital health care. 독일 디지털 헬스케어 법제를 구성하는 일련의 법률들 중 환자데이터보호법은 전자환자기록에 대한 환자의 통제권 및 의사의 책임 등을 규정하며, 디지털헬스케어법 및 디지털헬스케어 및 돌봄의 현대화법은 건강관리 및 치료를 도와줄 디지털 앱에 관한 상세한 내용을 규정한다. 위 일련의 법들에 의해, 전자처방전이 재택치료, 외래 집중치료, 사회요법, 치료제와 보조기구, 마취제 기타 처방전이 필요한 의약품 영역에서 도입되고 이를 보충하는 규정들을 제정되었다. 다만 마취제에 대한 처방을 전자처방전의 형식으로 발급하기 위해 필요한 조치는 gematik이 정하도록 위임되어 있다. 또한 검사결과, 진단서, X레이, 예방접종증명서, 산모수첩, 소아수첩 등의 내용은 앞으로 전자환자기록에 저장된다. 의료보험 피보험자는, 어떤 개인정보가 전자환자기록에 저장되고 어떤 개인정보가 삭제될 것인지, 개별적인 경우 누가 전자환자기록에 접근할 수 있는지를 결정할 수 있다. 의료보험 피보험자는 의사에게 자신의 전자환자기록을 채워줄 것을 청구할 수 있다. 환자기록을 완성하는 의사나 병원에 대해, 의료보험에서 일정액의 보수가 지급된다. 의료보험 피보험자는 전자환자기록에 포함되어 있는 데이터를, 임의로 연구를 위해 사용하도록 기부할 수 있다. 또한 디지털 앱이 사람들의 필요에 맞춰 사용친화적인 앱으로 발전하고 의사와 환자 사이의 집중적인 의사소통과 협력을 통해 강화하는 것을 목적으로 하는 법률이 입법화되었다. 이러한 디지털 앱은, 사람들이 입원하지 않고 건강을 일상생활에서 관리하는 것을 도와주는 돌봄 앱과 질병 치료에 도움이 되는 의료용 앱으로 나뉜다. 돌봄 앱 사용비용도 일정 금액 한도 내에서 요양보험에서 지원받을 수 있다. 디지털 의료용 앱은 당뇨병학, 심장병학, 언어치료, 심리치료, 물리치료 기타 여러 분야에 적용가능할 것으로 기대되고 있다. 디지털 의료용 앱에서 데이터보호와 정보안정성이 강화하기 위한 규정들도 신설되었다. 전자환자기록, 디지털 돌봄 앱과 의료 엡 모두 개인에게 민감한 건강관련 정보들이 디지털화되어 유통가능해지기 때문에 타인이 무단으로 개인정보에 접근할 위험이 높아지고, 따라서 위 법률의 입법과정에서 개인정보보호가 중요한 논점으로 등장했다. 또한 독일 입법자들은 디지털헬스케어를 위한 기반이 기술적으로 안전하게 운영될 수 있도록 여러 가지 장치를 마련하고 있으며, 디지털헬스케어로 발생하는 비용의 일부를 건강보험이나 요양보험이 부담하도록 하여, 이 제도가 기술적, 재정적으로도 안정적으로 운영될 수 있도록 배려하고 있다.

역량 중심 접근법에 입각한 의료 정의론 연구 : 노만 대니얼즈의 논의를 넘어서

목광수(Kwangsu Mok) 사회와철학연구회 2014 사회와 철학 Vol.0 No.27

현대 다원주의 사회에서 가장 주목받고 있는 의료 분배 체계는 사회 구성원들의 기본적 의료에 대해서는 평등한 접근을 보장하는 기본층(the basic tier)을 유지하면서도 개인의 자유로운 의료 구매 행위가 이루어지는 상위층(the upper tier)을 허용하는 이원화 의료 체계(the two-tiered system of health care)이다. 왜냐하면 이러한 이원화 의료 체계는 자유로운 구매 행위 보장과 적정 수준의 의료 보장이라는 두 가지 직관을 잘 반영하고 있기 때문이다. 이러한 이원화 의료 체계를 이론적으로 정당화하고 현실적으로 작동가능하게 할 것으로 기대되는 의료 분배 정의론 가운데 대표적인 논의가 노만 대니얼즈(Norman Daniels)의 자유주의적 평등주의(liberal egalitarianism) 논의이다. 대니얼즈는 사회 구성원들의 정상적인 기능(speciestypical normal functioning)을 보장해야 한다는 확장된 공정한 기회균등 논의와 심의 민주주의적 방식의 합당한 결정의 책임(accountability for reasonableness) 논의를 결합한 의료 정의론을 제시하여 이러한 이원화 체계의 이론적 근거를 제시하고 있다. 본 논문의 목적은 이러한 대니얼즈의 의료 정의론이 이원화 의료 체계를 지탱하는 이론으로 적합한지를 검토하는 것이다. 본 논문은 대니얼즈의 논의가 기본층을 보장하는 이론적 토대를 충분히 제시하지 못할 뿐만 아니라, 잘못된 가치에 토대를 두고 있어 하향 평준화(leveling down)의 문제를 야기한다고 비판한다. 또한 대니얼즈의 논의에서 정상적인 기능 논의와 합당한 결정의 책임 논의의 결합이 내적인 연관성에 기반을 두기보다는 현실적 필요에 의한 것이어서 이론적으로도 불완전하다고 비판한다. 이러한 이론적 취약성은 대니얼즈의 의도와는 달리 이원화 의료 체계에서 기본층의 무력화로 인한 의료의 영리화 또는 상업화, 즉 의료 민영화를 초래할 수 있으며, 이러한 귀결은 개인의 적정 수준 의료가 보장되어야 하다는 직관과 배치된다. 본 논문은 대니얼즈의 한계를 극복할 수 있는 대안으로 역량 중심 접근법(capability approach)에 입각한 의료 분배 정의론을 제시하고자 한다. 역량 중심 접근법에 입각한 의료 분배 정의론은 실질적 자유이면서 인간의 기본 조건인 역량을 분배의 대상으로 설정하고, 분배의 기준은 적정 수준의 의료 최소치를 충족(sufficiency)하려는 정의관을 제시하여 기본층을 확고하게 유지할 수 있는 이론적 토대를 마련하기 때문이다. 더욱이 이러한 정의론은 의료 자원의 부족이라는 현실적 제약 하의 분배 논의를, 역량 개념과 내적 연관성을 갖는 행위주체성, 그리고 이를 토대로 하는 심의 민주주의를 통해 제시한다는 점에서 기본층을 확고하게 유지할 수 있는 이론적 토대를 마련하고 있기 때문이다. 본 논문이 제시한 역량 중심 접근법에 입각한 의료 정의론은 자유로운 의료 구매 행위 보장과 적정 수준의 의료 보장이라는 두 가지 직관을 잘 반영하는 이원화 의료 체계를 효과적으로 구현할 수 있을 것이다. In this paper, I search for a theory of just health care that can effectively sustain the two-tiered system of health care based on two intentions: (1) freely allowing citizens to purchase health care of their choice while still (2) guaranteeing a decent base level of health care. For this purpose, I examine a libertarian theory of just health care and Norman Daniels"s liberal egalitarian theory. Daniels’s theory has been popular, and the community expects his work to support the twotiered system of health care. I criticize Daniels’s theory in that it can not sustain the two-tiered system and instead results in the same privatization of health care as a libertarian theory does. This is because Daniels’s theory of accountability for reasonableness may collapse the two-tier system, resulting in leveling a basic tier down or permitting trading people’s health as species-typical normal functioning against other values and priorities. In addition, Daniels’s theory is theoretically incomplete. This is because there is no internal connection between his main arguments - species-typical normal functioning and accountability for reasonableness, and the latter seems to be additional justifications for the reality of scarce medical resources. I argue that a theory of just health care based on the capability approach can effectively sustain the two-tiered system based on the two intentions. This is because in the capability approach, basic or central capabilities such as “capability to be healthy” should be absolutely guaranteed because they are important and necessary for human beings" quality of life. Furthermore, in the capability approach, the concept of capability theoretically relates to agency and public reasoning. Namely, this means a deliberative democracy, which attempts to trade off values in situations of resource scarcity. For this reason, in a theory of just health care based on the capability approach, basic or central capabilities (i.e. the capability to be healthy) cannot be traded off. Therefore, I argue that a theory of just health care based on the capability approach can effectively sustain the two tiered system of health care based on the two intentions - freely allowing citizens to purchase health care of their choice and guaranteeing a decent base level of health care.

중국 보건의료체제의 재구축과 발전 방향

장영석 ( Young Seog Jang ) 현대중국학회 2010 現代中國硏究 Vol.12 No.1

본 글은 후진타오 지도부가 등장한 뒤 중국의 보건의료체제의 재구축 정책의 내용과 문제점을 분석하고 있다. 분석의 주된 대상은 보건의료체제를 구성하는 기본의료보장체계와 공공보건의료 서비스체계의 재구축과 관련된 개혁 정책들이다. 기본의료보장체계 재구축 정책과 관련해서는 먼저 도시직공기본의료보험제도, 신형 농촌합작의료제도, 도시 주민기본의료보험제도의 내용과 각 지역의 실천 내용을 분석한 뒤 이들 제도와 ‘신 의약 개혁 방안’이 제시하고 있는 ‘전민 기본의료보장체제’ 확립 목표와의 관계를 분석한다. 본 글은 2020년까지 ‘전민 기본의료보장체제’를 확립한다는 중국 당국의 구상은 이미 확립되어 있는 도시 직공기본의료보험제도, 신형 농촌합작의료제도, 도시 주민기본의료보험제도를 어떤 방식으로 전민 기본의료보장 체제로 통합할 것인지에 대해 명확하게 밝히지 않는 모호한 점이 존재하기 때문에 전민 기본의료보장체제 확립 목표는 제도적으로 좀 더 보완될 필요가 있다고 주장한다. 한편, 공공보건의료 서비스체계 재구축 정책과 관련해서는 기층 보건의료기구의 재구축, 공립병원 개혁, 약품 유통체계 개혁 정책을 검토한다. 본 글은 후진타오 지도부의 재정 투입 증가와 인본주의를 중심으로 하는 발전 패러다임의 전략적 변화로 중국의 공공보건의료 체계는 크게 개선되고 있다고 평가한다. 그렇지만 약품 판매 영차율 제도 도입에 따른 공립병원 수입 감소 문제를 보완할 제도적인 장치가 필요하고, 약품의 통일적인 구매와 배송제도 도입에 따른 지대추구행위를 감독할 수 있는 제도적인 장치가 보완되어야 한다고 주장한다. 무엇보다 본 글은 중국 당국의 정책 투명성이 결여된 상황에서 정부의 정책 결정이 확대되는 방향으로 공공보건의료 서비스체계가 재구축되고 있기 때문에 정부 행위를 규제할 수 있는 ‘좋은 거버넌스’를 구축할 필요가 있다고 주장한다. 본 글의 결론에서는 보건의료체제 재구축 정책을 입안할 때 개인의 자주성과 사회적 단결의 제고가 경제적 효율성보다 더 중요한 이유를 설명한다. This article analyses the policy and the direction of China`s new round of health care system reform after Hujintao. The main analytical focus of this article is on the policies which are related to restructuring of basic health care insurance system and public health care service system which consist of China`s health care system. In terms of basic health care insurance system reform, this article, first of all, analyses policy details of urban employees` health care insurance, new rural co-operative medical system and urban residents` health care insurance. This article argues the target of establishing national basic health care insurance system until 2020 which Hujintao`s government promotes is ambiguous, because it does not make clear how to integrate urban employees` health care insurance, new rural co-operative medical system and urban residents` health care insurance into the national basic health care insurance system. If Chinese government would establish the national basic health care insurance system, it needs to make a clear policy on how to unify each of the different levels of health care systems, health care delivery institutions, and governmental health care administrations. In terms of the restructuring of public health care service system, this article analyses the problems of reform of community primary health care provider system, public hospital, and drug distribution system. Although China`s public health care service system is improving by virtue of Hujintao`s government financial investment and strategical change of the paradigm of development which puts emphasis on humanism and co-development of economy and society, some new problems arise in the process of reform, so this article argues that the policy of public health care service system reform also needs to be complemented carefully. Because Hujintao`s government is driving the government-dominated solution under circumstances lacking of government transparencey. Above all, this article argues that Chinese government need to set up `good governance` which supervises the behavior of health care adminstration. And in terms of the reform of drug distribution system, while Hujintao`s government introduced a `zero-profit ratio`(lingchalu) policy, local government did not balance up public hospitals` loss of income, so this article argues the need to introduce new policy guidelines which will guarantee the health of finance of the public hospitals. In addition, the unified purchase and unified delivery(tong gou tong pei) system may cause rent-seeking behaviors between health care administration and pharmaceutical producers, this article also argues that there is a need to set up `good governance` which supervises the governmental behaviors. In the conclusion, this article explains why the principle of individual sovereignty and social solidarity is more important than the economic efficiency in restructuring of the health care system.

Multidisciplinary Practice Experience of Nursing Faculty and Their Collaborators for Primary Health Care in Korea

김미자,정향인,안양희 한국간호과학회 2008 Asian Nursing Research Vol.2 No.1

Purpose This study aimed to describe the range of participation of nursing faculty members and their collaborators in multidisciplinary primary health care in Korea and to analyze facilitators, benefits, barriers, and learned lessons. Methods An exploratory descriptive research design was utilized. A total of 13 nursing faculty members and 13 multidisciplinary collaborators were interviewed face to face using a brief questionnaire and semi-structured interview guide. Descriptive statistics, comparative analysis, and content analysis were used for data analysis. Results About 43% of the nursing faculty had multidisciplinary primary health care experience. Facilitators included a government-funded research/demonstration project, personal belief and expertise in primary health care, and well-delineated role boundaries. Benefits included improved quality of life, more convenient community life, meeting multifaceted needs of community residents, and enhanced research activities. Barriers were lack of teamwork; territoriality and self-protective behaviors; lack of insight into primary health care among stakeholders; nurses undervaluing their work; and the rigid bureaucratic system of public health centers. Learned lessons were the importance of teamwork and its synergistic benefits, the importance of conducting clinically relevant research, having the government’s support in the improvement of public health, developing health policies through multidisciplinary primary health care (M-D PHC) work, and respecting each other’s territory and expertise. Conclusion Teamwork should be included in all health professions’ curricula, and nursing clinical practicums should include primary health care in all specialty areas. More faculties should engage in multidisciplinary primary health care. The benefits of a multidisciplinary approach to primary health care outweigh the difficulties experienced by multidisciplinary team members. The findings of this study may be useful for future multidisciplinary primary health care work worldwide. [Asian Nursing Research 2008; 2(1):25–34] Purpose This study aimed to describe the range of participation of nursing faculty members and their collaborators in multidisciplinary primary health care in Korea and to analyze facilitators, benefits, barriers, and learned lessons. Methods An exploratory descriptive research design was utilized. A total of 13 nursing faculty members and 13 multidisciplinary collaborators were interviewed face to face using a brief questionnaire and semi-structured interview guide. Descriptive statistics, comparative analysis, and content analysis were used for data analysis. Results About 43% of the nursing faculty had multidisciplinary primary health care experience. Facilitators included a government-funded research/demonstration project, personal belief and expertise in primary health care, and well-delineated role boundaries. Benefits included improved quality of life, more convenient community life, meeting multifaceted needs of community residents, and enhanced research activities. Barriers were lack of teamwork; territoriality and self-protective behaviors; lack of insight into primary health care among stakeholders; nurses undervaluing their work; and the rigid bureaucratic system of public health centers. Learned lessons were the importance of teamwork and its synergistic benefits, the importance of conducting clinically relevant research, having the government’s support in the improvement of public health, developing health policies through multidisciplinary primary health care (M-D PHC) work, and respecting each other’s territory and expertise. Conclusion Teamwork should be included in all health professions’ curricula, and nursing clinical practicums should include primary health care in all specialty areas. More faculties should engage in multidisciplinary primary health care. The benefits of a multidisciplinary approach to primary health care outweigh the difficulties experienced by multidisciplinary team members. The findings of this study may be useful for future multidisciplinary primary health care work worldwide. [Asian Nursing Research 2008; 2(1):25–34]