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.

B형 간염에 대한 경기도 지역 일부 여고생들의 지식, 태도 및 실천에 관한 연구

신영전,박남희,김수근,최보율 대한보건협회 1995 대한보건연구 Vol.21 No.2

선진국들에 비해 상대적으로 높은 B형 간염 유병률을 보이고 있는 우리나라의 경우 간염백신이 개발되어 사용된지 10여년이 경과 했음에도 불구하고 B형 간염 유병률 감소의 증거가 보이지 않는 상황에서 간염검사 및 예방접종행위에 관련된 여러 요인들을 파악하고 B형 간염관리에 대한 지식, 태도 및 실천정도와 이에 영향을 미치는 요인간의 상호 관계에 대한 이하는 B형 간염의 관리대책을 세우는데 필수적이다. 본 조사는 집락추출법에 의해 선정된 경기도 지역 9개 여자고등학교 1학년생 1,181명을 대상으로 1992년 4월 15일부터 4월 27일까지 자가설문지법을 이용, B형 간염에 대한 지식, 태도 및 실천에 관하여 조사를 시행하였다. 조사결과 대상자의 B형 간염에 대한 자가판단 지식정도는 낮았으며, 지식의 정확도는 대상자의 일반적인 특성들과 상관관계를 보이지 않았으며, 지식의 인지도는 부모의 교육수준과 가족 간장질환 과거력과 상관관계를 보였다. 조사 대상자의 간염전파에 대한 태도는 지식의 정확도 및 인지도와 상관관계를 보였으며 예방접종 및 치료에 대한 태도는 모친 교육수준 및 인지도와의 상관성을 보였다. 조사 대상자의 B형 간염에 대한 실천의 지표로서의 간염검사는 부친 교육수준, 가족 및 본인 간염 과거력에 따라 유의한 차이가 있었으나 간염전파와 예방접종 및 치료에 대한 태도와는 상관관계를 보이지 않았다. 또한, 예방접종은 부모의 교육수준과 가족 및 본인 간염 과거력과 상관관계를 보였으며, 간염전파에 대한 태도와는 상관관계를 보이지 않았지만 예방접종과 치료에 대한 태도와는 상관관계를 보였다. 따라서, 낮은 자가판단 지식정도, 정확도와 인지도의 불일치 등은 적절한 보건교육이 필요함을 보였으며, 대상 학생들의 B형 간염에 대한 실천의 지표로서의 간염검사와 예방접종은 학생 본인의 지식이나 태도에서 연유되기 보다는 부모의 교육수준과 같은 일반적인 요인들에 의해 결정된다는 사실을 알 수 있었다. It has been generally accepted that the level of the prevalence of hepatitis B in Korea is higher than that of other developed countries. It is ten years that hepatitis B vaccine was used in our country, but there was no clear evidence of declining of prevalence of hepatitis B. Therefore, it was important to understand factors associated with knowledge, attitude, and practice(KAP), such as serologic test and vaccination of hepatitis B. 1,181 juniors of 9 high schools for girl in Keong-ki Do was selected through the cluster sampling method. This study carried out from 15 March to 27 March 1992. Every study subject filled up self-administered questionnaire about KAP of HBV infection. From the study, we could find that the self estimated level of knowledge for hepatitis B was relatively low, the accuracy score of HBV infection was not statistically associated with general characteristics of subject. However, the recognition score was statistically associated with father and mother's educational level and family history of liver disease. The accuracy and recognition scores had influence on the attitude on transmission of HBV infection and mother's educational level and the recognition score had influence on the attitude on vaccination and treatment of HBV infection. There was statistical association between the serologic test as the index of practice and father's educational level, family history of liver disease and past history of liver disease, but not the attitude on transmission, vaccination and treatment. The vaccination, the other index of practice, was statistically associated with father and mother's educational level, family history of liver disease, past history of liver disease and the attitude on vaccination, not the attitude on transmission. Therefore, we thought that the appropriate health education for girls of high school was essential for the program for prevention of hepatitis B, because there was low level of the self estimated knowledge for hepatitis B and the discordance between the accuracy and recognition score. We found that the practice of subject such as serologic test and vaccination of hepatitis B was associated with general characteristics of subject, such as father and mother's educational level etc., not knowledge and attitude for hepatitis B. And, it was necessary to consider this general characteristics in the vaccination program of hepatitis B.

일부 병원에서의 입원비 본인부담양상

신영전,유원섭,하헌영,정설희 한양대학교 의과대학 2000 한양의대 학술지 Vol.20 No.1

The purpose of this study was to estimate the proportion of user charges out of total treatment costs and to investigate the occuring status of the charge of non-benefit service. The data were collected from 6 hospitals in 3 cities (Seoul 2, Incheon 3, Shihung 1), which containing 1,752 discharge-bills of discharged patients insured by health insurance. The data were analyzed after standardization of the items of non-benefit services. The result are as follows; 1. the average percent of the cost-sharing of discharged patients was 38.1%(benefit : 15.5%, non-benefit : 22.6%) and the proportion of the cost-sharing due to non-benefit services was greater than that due to benefit services. 2. The occurrence rate and the occurred number of non-benefit services were different among hospitals and showed characteristic occurrence rate in individual hospitals. 3. In acute appendicitis, the characteristics of the occurrence rate and the occurred number of non-benefit services by individual hospitals was similar to those of hospitals. It suggest that the hospitals intentionally applied non-benefit item to patients in order to increase their profit. These findings suggest that the burden of cost-sharing is still high especially due to non-benefit services, so it is necessary to extend the coverage of insurance benefits and to develop management system for the appliance of non-benefit services. Regarding the discharge-bill, all service charges should be included in the bill.

통일 후 북한 의료안전망 구축방안

신영전 대한의사협회 2013 대한의사협회지 Vol.56 No.5

Establishing social security networks for the reunification of the Koreas is important to minimize social disturbances. Above all, it is highly critical to establish a medical safety net. The non-political and humanitarian aspects of medical services may be used as a valuable tool to initiate peaceful exchanges between the two Koreas amid geopolitical tensions. It is necessary to determine principles and set up strategies in order to build medical safety net in the course of reunification. A staged approach is required. In the first phase, we need to establish a system to ensure expedited basic medical services while South Korea’s medical insurance, public medical care, and emergency medical service systems are replicated in the second phase. The North Korean system then needs to be developed into a more robust medical safety net in the third phase. In order to engage in this approach successfully, it is necessary to close gaps and promote trades between the two Koreas, conduct consistent research and monitoring, and secure a professional personnel pool. Along with such efforts, it will also be necessary to coordinate other political, social, economic, and cultural policies and processes of establishing other social security nets. The successfully established medical safety net will play an important role in maximizing the benefits of reunification.

현재 진행되고 있는 남북한 의료협력사업 : 영유아 지원 사업을 중심으로

신영전 대한소아청소년과학회 2008 Clinical and Experimental Pediatrics (CEP) Vol.51 No.7

The economic recession of North Korea has been prolonged, the need for humanitarian assistance for the women and children of DPRK has been raised. In March 2006, South Korean government signed MOU with World Health Organization (WHO) to financially support "Improving Women's and Children's Health in DPRK (IWCH)" project. The assistance projects through UNICEF and the non-government organizations of South Korea were also followed. IWCH project consists of three parts; nutrition, disease management, children and maternity care. The first term (2006-2007) of the project leading by WHO was finished, and the second term (2008-2010) is just begun. The projects driven by NGOs have relatively been delayed due to difficulties in negotiating on project contents and places with North Korea. Recently, however, re-modeling processes of an obstetric/gynecology hospital and a children hospital in Nampo were started. Up to recently, South Korean government has played only a limited role in the humanitarian assistance for North Korea. IWCH project is, however, a full-scale initiative driven by government based on a systematic review of need and priorities. A significant amount of budget and relatively long term (five year) project compare to the previous short term and small size programs were expected to make more meaningful achievement. Despite these positive aspects, the project remains a list of unsolved problems a lack of mutual trust, a different decision making process between South and North Korea, a lack of conflict management process, and unpredictability and complexity of international politics. In spite of such kind of political uncertainty, the health care sector will be a leading area in the process of improving relationship between South and North Korea, particularly, humanitarian assistance for women and children will play a crucial role in the process. The successful implementation of IWCH project, therefore, will contribute to provide the reference model in developing the mutually constructive relationship between South and North Korea. (Korean J Pediatr 2008;51:671-689)

국가정신보건체계의 새로운 모색 : 정책과제를 중심으로

신영전 漢陽大學校 精神健康硏究 1999 精神健康硏究 Vol.18 No.-

미국 사회복지정책변화와 메디케이드 매니지드 케어 도입 및 확대 : Lessons for Korea

신영전 한국사회보장학회 2004 사회보장연구 Vol.20 No.1

메디케이드(Medicaid)는 빈곤층에게 의료서비스와 건강관련서비스를 제공하는 미국 연방정부와 주 정부의 협력 프로그램이다. 1970년대 이후 미국 메디케이드 제도가 당면하고 있는 과제는 크게 두 가지인데 하나는 빈곤층의 건강문제를 지키는 건강안전망으로서의 기능을 더욱 강화하는 것이며, 다른 하나는 진료비의 급증에 따른 연방정부와 주정부의 재정적 부담에 대해 적절히 대응하는 것이다. 이 두 가지 과제를 해결하기 위해 미국의 연방정부와 주정부는 다양한 시도를 해오고 있으며 이 가운데 가장 기본적인 전략으로 선택한 것이 매니지드 케어의 도입이다. 1973년 건강유지접의 제정이후 매니지드 케어는 지속적으로 성장하여 2002년 현재 전체 메디케이드 가입자의 58%가 매니지드 케어 방식에 의해 서비스를 제공받고 있다. 1970년대 경제침체와 1981년 레이건의 집권 및 1990년대 공화당의 의화장악이라는 정치환경의 변화는 루즈벨트 이후 지속되어 오던 자유주의적 복지체계를 보수적 복지체계로 전환시켰다. 이러한 변화는 미국 보건복지 전반에 걸친 민영화(영리화 또는 상업화)를 야기하였는데, 1980년 이후 민간 영리 기관을 중심으로 한 메디케이드 매니지드 케어의 급속한 성장은 매니지드 케어의 내부적 운영특성이 가지는 장점에 기인하기보다는 이러한 변화의 연장선상에서 상호 긴밀한 관계를 맺으며 이루어진 것이었다. 따라서 미국 메디케이드 매니지드 케어의 다양한 경험을 참고할 때에는 그 내부 운영방식에 대한 분석 뿐만 아니라 그 도입과 확산이 이루어진 미국의 정치, 경제, 사회적 상황 및 사회복지정책의 변화들과의 관계에 대한 보다 분명한 이해와 비판을 기반으로 우리 사회의 적용 가능성을 검토하여야 할 것이다. 또한 여러 가지 제한점에도 불구하고, 미국 정부가 메디케이드 정책을 통해 보건의료전반에 걸쳐 정부의 정책기조를 관철시켜나가는 운영 전략, 연방정부가 주정부와 함께 정책수립과 집행과정에서 만들어내는 역동의 경험들, 그리고 메디케이드 매니지드 도입 과정에서 비용절감과 잘 개선을 위해 동원된 다양한 프로그램으로부터는 많은 아이디어와 기술적 도움을 얻을 수 있을 것이다. Medicaid, codified under the Title XIX of the Social Security Act, is a joint federal-state program to assist the poor for health and related services in the United States of America. Since 1970s, Medicaid has been faced with two problems: one hand is that it has to enforce its role as a health safety net and the other hand is that it has to adequately respond to the rapidly increasing fiscal burden of the US. To solve the problems, the federal and state governments have conducted various trials, but the most important major strategy that they finally chose was the introduction of Managed Care. After the enactment of the Health Maintenance Organization Act in 1973, Medicaid Managed Care has rapidly increased, and by 2002, more than 58 percent of Medicaid beneficiaries were enrolled in managed care arrangements. The economic recess in the 1970s and the changes in the political environment including the election victory of Ronald Reagan in 1981 and the dominance of the Republican Party in the congress since 1990s, made the transformation of the US welfare system from the liberal system to the conservative system. The conservative welfare system has changed the welfare including the health care service system into a more privatized one. The rapid increase in number and the commercialization of Medicaid Managed Care since the 1980s were closely linked to these kinds of changes of social policy under the political-economic environment rather than its intrinsic strength as an operational principle. When we would like to refer to the experiences from the introduction of Medicaid Managed Care, we must place it in the understanding of political context of the social policy in the United States of America. In spite of the limited application of the U's experiences to the health policies in Korea, some of them, especially the political strategy of the government using Medicaid as an important political vehicle for the health policy, political dynamics that the relationship between the federal and state governments is producing, and various idea and techniques for cost containment and quality improvement will be helpful to plan and implement health policies for the poor in Korea.

일차의료체계의 중요성과 함의 : 효과적이고 민주적인 ‘서로 돌보는 공통체’로의 전환

신영전 참여연대사회복지위원회 2019 월간 복지동향 Vol.- No.254

연구는 누구의 것인가?: ‘알기 쉬운 요약’을 시작하며

신영전 한국보건사회연구원 2021 保健社會硏究 Vol.41 No.1