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.

미군정 초기 미국 연수를 다녀온 한국인 의사 10인의 초기 한국보건행정에서의 역할

신영전 ( Young Jeon Shin ),서제희 ( Jae Hee Seo ) 한국보건행정학회 2013 보건행정학회지 Vol.23 No.2

‘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.

대한의사협회 휘장의 소사 : 아스클레피오스의 지팡이와 헤르메스의 지팡이

신영전(SHIN Young-Jeon) 大韓醫史學會 2007 醫史學 Vol.16 No.1

An emblem represents the identity of an organization. Through the emblem of an organization, they differentiate the members from others and reinforce the membership, homogeneity, and pride. It is also a tool that an organization officially publicizes its mission and values. The symbol designed by Cho, Byungduk was announced as the first emblem of Korean Medical Association(KMA) on October 31st 1947. His design work has the caduceus with the Taeguk sign on the top, the symbol of Korea, and the Red Cross in the background including the name, ‘KMA’. Since then, the emblem was revised three times: in 1964, 1973, and 1995. The current symbol is based on the design of the first one. Although Asklepian, the single serpent-entwined staff of Asklepios, is the one known as the symbol of medicine, this emblem takes the caduceus of Hermes who is the patron god of merchants, thieves, and travelers. The mistake comes from the unawareness of the distinction between the caduceus of Asklepios and Hermes. Moreover, it proves that U. S. Army Medical Corps(USAMC) heavily influenced the reconstruction of Korean health care system including KMA. The USAMC has used the symbol of caduceus since 1902. In 1947, the year that the first emblem of KMA was established, Southern part of Korea was governed by the United States Military Government(USMG, 1945-1948). The current emblem of KMA brings up a question whether we should continue to use the symbol that was taken from USMAC in the historical period of USMG governance. Celebrating 100th anniversary year of KMA, KMA needs to re-evaluate the appropriateness of the KMA symbol.

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.

보건운동가로서 춘곡 양봉근 (春谷 楊奉根 1897- 1982)의 생애

신영전(SHIN Young- Jeon),윤효정(YOON Hyo- Jung) 大韓醫史學會 2005 醫史學 Vol.14 No.1

국가정신보건체계 모형개발과 정책과제

신영전(Young-Jeon Shin),남정현(Jung Hyun Nam) 대한사회정신의학회 2001 사회정신의학 Vol.6 No.1

국가정신보건정책은 그 문제의 심각성, 문제의 크기 측면 모두에서 중요한 국가보건정책 중의 하나임에도 불구하고, 그간 상대적으로 정책의 관심에서 벗어나 있었으며, 체계적인 접근이 이루어지지 못해왔다. 그러나 1995년말 정신보건법의 제정과 보건복지부내 정신보건과의 설치이후 정신보건부문에 빠른 변화가 나타나고 있다. 이 연구에서는 국가정신보건체계의 궁극적인 목표를‘국민들의 건강한 삶의 연장을 위한 정신건강의 증진’,‘정신질환을 가진 사람들의 건강한 삶의 연장’,‘정신건강의 불균형 해소’로 설정하였다. 개념적인 목표로‘정신질환자 및 가족들의 기본적 삶의 수준확보’,‘정신보건서비스의 접근도 향상’,‘정신보건서비스의 질 향상’,‘효율적인 국가정신보건체계구축’으로 설정하고 이의 달성을 위한 국가정신보건체계를 제시하였다. 또한, 이 체계 모형에는 국가정신보건정책의 대상, 서비스의 유형과 수준들을 포함하였다. 또한 제안한 국가정신보건체계의 구축전략으로써 자원부문, 조직 및 전달체계부문, 재정부문, 관리체계부문의 정책안들을 제시하였다. 이상의 작업에 설정한 국가정신보건의 목표, 모형 및 시행전략은 앞으로도 많은 전문가와 환자 및 가족들의 검토와 비판을 통하여 더욱 현실적이고 구체적인 정책안으로 발전하여야 할 것이다. In spite of its importance and seriousness, mental health has received little attention from politicians and administrators and a systematic approach has been lacking in Korea for a long time. However, the legislation of the Law for Mental Health in 1995 has brought about dramatic changes in the area of mental health. This study was conducted to develop a model and strategies for a national mental health system in Korea. Four goals and six objectives have been proposed. The four goals are: ensuring the essential conditions for life, and improving the accessibility, quality and efficiency of mental health service. The six objectives are:to reduce the incidence and prevalence of mental illness, to reduce mortality associated with mental illness, to reduce the extent and severity of problems associated with specific mental disorders, to develop mental health services, to promote good mental health and reduce the stigma attached to it, and to promote the psychological aspects of general health care. The national mental health system model has been designed to achieve these goals and objectives. The model includes the target population, the type and level of mental health services and four infra-structures - resource and organization, delivery, management and economic support. Finally, political measures and strategies to establish the national mental health system have been proposed.

미 충족의료의 현황과 관련요인 -1차, 2차 한국복지패널자료를 이용하여-

신영전 ( Shin Young-jeon ),송정인 ( Shon Jeong-in ) 한국보건사회연구원 2009 保健社會硏究 Vol.29 No.1

한 국가의 건강보장제도 평가 기준인 의료서비스이용 현황을 살펴보기 위해 의료필요가 있음에도 불구하고 사회경제적 요인으로 인해 적절한 의료이용을 하지 못하는 미 충족의료 현황을 분석하고 관련요인을 분석하는 것은 중요하다. 이 연구에서는 1차, 2차 한국복지패널 자료를 이용하여 경제적 이유로 인한 미 충족의료 현황과 관련요인을 분석하였다. 우선 연도별 단면적 기술 분석과 관련요인 분석(로지스틱 회귀분석)을 수행하고 2개년도 자료를 연동하여 동태적 기술 분석과 관련요인 분석(로지스틱 회귀분석)을 수행하였다. 단면적 분석결과 1차, 2차 한국복지패널자료의 미 충족의료 유경험 빈도는 각각 5.54%, 2.99%이었고 미 충족의료 유경험에 관련되는 요인으로 가구주 연령, 교육, 주관적 건강상태와 가구 소득계층이 유의하였는데 특히 가구 소득계층과 가구주 주관적 건강상태가 가장 유의하였다(p<0.05). 동태적 분석결과 2년 동안 미 충족의료를 한번 이상 경험할 가능성, 충족군에서 미충족군으로 추락할 가능성, 미충족군에서 미충족군으로 계속 잔류할 가능성에 관련되는 요인으로 가구 소득계층과 가구주 주관적 건강상태가 유의하였다(p<0.05). 분석 및 자료의 한계점에도 불구하고 이러한 분석 결과는 정책적으로 미 충족의료를 개선하기 위해 충분한 소득 지원과 건강수준을 보호, 증진하는 것이 여전히 중요함을 시사한다. A study on unmet medical need is instrumental to understanding the condition of medical utilization as a measure for the evaluation of a national health care system. Using the 1st and 2nd waves of Korea Welfare Panel Data, the prevalence and association factors of unmet medical need due to economic difficulty were analysed. For this ends, the cross-sectional analysis and the longitudinal analysis with descriptive and analytic step were implemented. The prevalence rates of unmet medical need were 5.54% (1st wave), 2.99% (2nd wave) and the significant factors associated with unmet medical need were householder`s age, householder`s education level, householder`s subjective health status, and house income class. The factors strongly associated with the probability of their having experienced unmet medical need, or having been shifted from the group with a met medical need to the one with an unmet medical need, or having been left in the group with an unmet need, were house income class and householder`s subjective health status. In spite of the limitations of analysis and data, these results suggest that policies for ensuring the adequate income security, the protection of health, and the promotion of health are still important for the poor to escape from the unmet medical need status.