우리나라 보건의료체계 특성과 한계에 관한 법적 고찰

김원일 사단법인 한국법이론실무학회 2024 법률실무연구 Vol.12 No.1

인구 고령화와 만성질환으로의 질병구조 변화, 공중보건위기 등 보건의료 패러다임 변화에 대처하기 위해서는 다음과 같은 국가보건의료체계의 개선이 필요하다. 첫째, 의사와 간호사 등 부족한 보건의료인력은 늘려야 한다. 그러나 단순히 양적인 측면만의 조정으로는 우리나라 보건의료인력의 공급 부조화가 해결되지는 않는다. 무엇보다 국가 책임을 확장하고 강화하여야 한다. 최근 정부가 의과대학 입학정원 2천 명 증원을 발표했다. 그러나 양적 확대만으로는 지역사회와 시민이 필요한 보건의료 요구를 해결할 수 없으며, 단지 필요조건만을 충족한 것에 불과하다. 국가가 시장에 개입하는 궁극적인 이유는 시장에 맡겨두어서는 자원이 필요한 영역에 효율적으로 분배되지 않기 때문이다. 특히 보건의료인력 양성에 있어 국가책임이 부재한 우리나라 현실에서 의사가 필요한 지역과 분야에 국가의 개입 없이 효율적으로 분배될 수가 없다. 그러므로 국가는 의사인력의 효율적인 분배를 위해 무상교육을 통해 의사 양성에 기여를 하고, 그 기여를 토대로 의사인력을 필수의료 영역과 지역의료에 배치하여야 한다. 둘째, 전체적인 병상 규모는 축소하되, 필수의료를 제공하는 300병상 이상 종합병원급 의료기관은 확충되어야 한다. 지역별 병상총량제를 도입하고, 중소규모 의료기관에 집중된 병상은 최소화하거나 기능전환을 유도하여야 한다. 반면 필수의료를 제공할 300병상 이상 종합병원급 의료기관은 권역별로 국가나 지방정부 책임하에 설립하여야 한다. 이러한 제도 및 정책개선을 통해 1차-2차-3차 의료기관의 역할과 위상을 정립하여야 한다. 셋째, 보건의료서비스에 대한 보상방식인 행위별수가제가 개선되어야 한다. 최근 의사집단은 의대 입학정원 증원을 두고, 의사수가 증가하면 의료이용량이 증가하여 건강보험재정이 파탄 난다고 주장한다. 그러나 우리나라 의사수는 OECD 국가 중 최하위이지만, 의료이용량은 OECD 국가 중에서 가장 높은 이유는 행위별수가제에 있다. 저출산․고령화로 인해 건강보험재정 수입은 감소하고 지출이 증가하는 위기 상황에서 행위별수가제만을 고집하는 것이야 말로 건강보험재정 파탄을 초래하는 것이다. 최근 가치에 기반을 둔 보건의료체계로의 전환의 필요성이 제기되고 있다. 보건의료 패러다임 변화 즉, 인구 고령화와 만성질환으로의 질병구조 변화, 기후변화 등으로 인한 감염병 대응, 필수의료 국가책임 등의 문제에 효율적으로 대처하기 위해 제시된 방안이다. 우리나라 보건의료체계 특성과 한계가 현실과 미래를 위해 변화하기 위해서는 무엇보다 ‘의료기관과 의사’ 중심의 낡은 보건의료법제에 대한 전면적인 개선이 선행되어야 한다. 법치주의 국가에서 우리나라 보건의료체계에 대한 정부 정책의 실패를 바로잡을 수 있는 유일한 방책은 ‘입법’에 있다. 입법을 통한 보건의료법제 개선으로 인구 고령화, 질병구조 변화, 공중보건위기 등 보건의료 패러다임 변화 대처해야 한다. In order to cope with changes in the healthcare paradigm, such as population aging, changes in disease structure to chronic diseases, and public health crises, the following improvements to the national healthcare system are necessary. First, the shortage of health care personnel, such as doctors and nurses, must be increased. However, simply adjusting quantitative aspects alone does not solve the imbalance in the supply of health and medical manpower in our country. Above all, state responsibility must be expanded and strengthened. Recently, the government announced an increase in medical school enrollment by 2,000 students. However, quantitative expansion alone cannot address the health care needs of the community and citizens; it only meets the necessary conditions. The ultimate reason for the state to intervene in the market is that if left to the market, resources will not be distributed efficiently to areas in need. In particular, in the reality in our country where there is no state responsibility for training health and medical personnel, doctors cannot be efficiently distributed to regions and fields in need without government intervention. Therefore, in order to efficiently distribute medical manpower, the state must contribute to the training of doctors through free education and, based on that contribution, deploy doctors to essential medical fields and regional medical services. Second, the overall size of hospital beds should be reduced, but general hospital-level medical institutions with more than 300 beds that provide essential medical care should be expanded. A regional bed capacity system should be introduced, and the number of beds concentrated in small and medium-sized medical institutions should be minimized or their function conversion should be encouraged. On the other hand, general hospital-level medical institutions with 300 or more beds to provide essential medical care must be established under the responsibility of the national or local government in each region. Through these system and policy improvements, the role and status of primary, secondary, and tertiary medical institutions must be established. Third, the fee-for-service system, which is a compensation method for health care services, must be improved. Recently, a group of doctors has advocated for an increase in medical school admissions, arguing that if the number of doctors increases, the use of medical services will increase and health insurance finances will be ruined. However, the number of doctors in Korea is the lowest among OECD countries, but the medical utilization is the highest among OECD countries because of the fee-for-service system. In a crisis situation where health insurance financial income is decreasing and expenditures are increasing due to low birth rate and aging population, insisting on only the fee-for-service system will lead to the collapse of health insurance finance. Recently, the need to transition to a value-based health care system has been raised. This is a proposed plan to efficiently respond to issues such as changes in the healthcare paradigm, that is, population aging, changes in disease structure to chronic diseases, response to infectious diseases due to climate change, etc., and national responsibility for essential medical care. In order for the characteristics and limitations of our country's health care system to change for reality and the future, comprehensive improvements to the outdated health care law system centered on 'medical institutions and doctors' must be carried out first. In a country governed by the rule of law, the only way to correct the failure of government policies regarding our country’s health care system is through ‘legislation.’ We must respond to changes in the healthcare paradigm, such as population aging, changes in disease structure, and public health crises, by improving the healthcare legal system through legislation.

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.

연구논문 : 타일랜드 공공의료제도의 특성과 변화: 탁신정부의 전국민의료보장제도 성립 전후 비교

송경아 ( Kyung Ah Song ) 한국동남아학회 2012 동남아시아연구 Vol.22 No.1

In 2001 election, Thaksin Shinawatra and his newborn Thai Rak Thai Party (TRT) made a campaign promise with a slogan called "30 baht cures all diseases." The coverage was finally extended nationwide with an enactment of the National Health Security Act in November 2002. Under the Universal Health Coverage Scheme (UCS), all Thai citizens became eligible for government-sponsored health service regardless of their income level, age, and place of residence. A comprehensive health care system is rare to find in Southeast Asia or any parts of the world, for such a scheme requires a strong financial commitment by the state and entails material interests of almost all people in the society. The health care institutions built under political contexts of a given country reveal a significant degree of influence that can either induce a specific path of development or restrict future political choices in regard to the pace and direction of policy change. In this sense, this paper first focuses on the enduring nature of the health care state in Thailand and then tries to provide explanations on the logic and working order of the public health care institutions before and after the Thaksin`s reform. As the provider, the Thai State has built health facilities and taken charge of the education and discipline of health workers. The number of public health facilities far outruns that of private facilities and health education is almost carried out by public universities. As the owner of hospitals and employer of doctors, the state has controlled over the occupational autonomy and collective influence of the professional health workforce. In addition, as the representatives of medical consumers, the state has directly taken responsibility for the welfare of its people by gradually expanding the benefit coverage to population. Thaksin and TRT made a transformation of the modern health care system in Thailand that has evolved over a century. However, the extent and scope of change was determined within the boundary of existing health infrastructures. The health reform was outlined in a direction that the state provided health services via contract with a hospital and an independent state organization checked the spending of health resources. Thaksin government successfully merged resources from four different health insurance schemes into the UCS to remove overlaps in coverage and guarantee a broader allocation of health resources to all segments of society.

노인복지정책의 전환: 재가복지시설에서 커뮤니티케어로의 전환 및 경상북도에 대한 시사점

김병문 대한정치학회 2020 大韓政治學會報 Vol.28 No.4

The government introduced integrated community care (community care) to establish a new elderly welfare system that links medical-health-care services, and expand support infrastructure as four key tasks, visit-type medical services, nursing home care services, and service connection. It has been promoting the universalization of community care after 2026, suggesting an autonomous delivery system. In this context, this study explains the problems of community care, focusing on the problems of securing living spaces, building care management, establishing roles of local governments, and linking medical-health-care services, as well as improving measures for community care. It was presented while applying it to Gyeongsangbuk-do. In the case of Gyeongsangbuk-do, it is advantageous to consider available space compared to other areas while pursuing expansion of residential support infrastructure to secure living space. The role of the care manager as the person in charge of establishing the delivery system is emphasized, and education is needed to improve the strategy of the care manager along with the qualification of the care manager. As for the care information window, it is necessary to prepare a model in which the private and public cooperate to link various services and provide them using big data. In order to break down the boundaries between medical-health-care and connect and integrate delivery systems, the community and its members should take the lead in health promotion by utilizing the knowledge and capabilities of Gyeongsangbuk-do to create a caring model. 정부는 지역사회통합돌봄(커뮤니티케어)을 도입하여 의료-보건-돌봄 서비스가 연계되는 새로운 노인복지 시스템을 구축하고 4대 핵심 과제로 지원인프라 확충, 방문형 의료서비스, 요양돌봄재가서비스, 서비스연계 자율형 전달체계를 제시하면서 2026년 이후 커뮤니티케어의 보편화를 추진하고 있다. 이러한 맥락에서 본 연구는 커뮤니티케어의 문제점으로 거주공간의 확보문제, 케어메니지먼트의 구축문제, 지방정부의 역할 정립 문제, 의료-보건-돌봄 서비스 연계의 문제점들을 중심으로 설명하고 커뮤니티케어의 개선 방안을 경상북도에 적용하면서 제시하였다. 경상북도의 경우 거주공간의 확보는 주거지원 인프라의 확충을 추구하면서 다른 지역보다 활용 가능한 공간을 고려해 보는 것이 유리하다. 전달체계 구축 담당자로서 케어 메니저의 역할이 강조되고 케어메니저의 자격 부여와 함께 케어메니저의 역략 증진을 위한 교육이 필요하다. 케어안내 창구는 민간과 공공이 협력하여 각종 서비스를 연계하여 빅데이터를 활용하여 제공하는 모델 마련이 필요하다. 의료-보건-돌봄간 경계를 허물고 전달체계간 연결와 통합을 위해서는 경상북도가 지닌 지식, 능력을 활용하여 건강증진에 커뮤니티와 그 구성원들이 주도적으로 참여하여 돌봄 모형을 만드는 방식을 추구해야 한다.

국제사회의 보건의료 원조 트렌드의 변화와 대북 보건의료 지원의 지속

문인철(Mun Inchul),송미경(Song Meekyong),여현철(Yeo Hyun-chul) 한국세계지역학회 2021 世界地域硏究論叢 Vol.39 No.4

우리 정부의 대북 인도주의 활동은 2010년 이후 사실상 중단되었다고 볼 수 있다. 이처럼 인도주의 활동 부분의 단절상황, 그리고 남북관계가 경색된 상황임에도 불구하고 제한적이지만 꾸준히 추진되었다고 평가받는 분야는 보건의료 지원사업이다. 문재인 정부 등장 이후 남북관계는 직전의 정부 때보다 좋은 상황이었음에도 불구하고 대북 인도적 지원사업은 대부분 국제기구를 통해 이루어졌다. 반면, 국제사회는 여러 제약 상황에서도 지속적인 대북 인도주의 활동을 전개했었는데, 국제사회는 UN 기구를 중심으로 하여 여러국제기구와 민간단체들이 식량과 농업, 특히 보건의료 영역에서 대북 지원 활동을 활발히추진하였다. 현재 국제사회의 원조 방향은 큰 변화를 나타내고 있다. 국제사회는 SDGs(지속가능발전목표)하에 지원에 대한 분야와 그 방식을 다각화 시키고 있다. 한국은 국제사회에서 보건의료 원조 비중이 두 번째로 높은 국가이다. 이는 그만큼 한국의 국제적 위상이 높아졌다는 것을 방증하는 대목이다. 이러한 역량과 평가를 종합해 볼 때 한국은 보건의료 분야를 비롯한 다양한 대북 지원을 위해 국제사회와의 협력을 이끌어 낼 수 있는 충분한 잠재력을 지니고 있다. 이러한 잠재력을 극대화 보건의료 부문, 나아가 대북 인도적 활동 및 지원을 담당하는 중추역할을 이행하기 위해서는 국내외 다양한 주체들 간 유기적 협력을 추진해야 할 것이다. 특히, 지속가능한 대북 지원을 위해서는 일관성 있는 원칙을 수립 및 이행시키면서 다른 한편으로는 북한의 니즈를 반영하기 위해 세부 지원 분야를 다양화시켜야할 것이다. 무엇보다 우리 정부는 남북한 정치․군사적 상황, 남북간 경색국면에서도 대북인도적 활동이 이루어질 수 있도록 법․제도적인 장치를 마련하고, 외교적인 노력도 병향시켜야 할 것이다. Most of South Korea s humanitarian activities against North Korea have been suspended since 2010. However, South Korea s health care support for North Korea was steadily promoted even in the face of a strained inter-Korean relations, but was virtually limited. Since the advent of the Moon government, humanitarian aid to North Korea has been mainly provided through international organizations, even though inter-Korean relations have been better than ever. On the other hand, the international community has continued to carry out humanitarian activities against North Korea in spite of various restrictions. In the international community, various international organizations and private organizations, led by the United Nations, actively promoted support activities for North Korea in the fields of food and agriculture, especially health care. Currently, the direction of development aid in the international community is showing a big change. The international community is diversifying its support fields and methods under the SDGs. Korea has the second highest proportion of health care aid in the international community. This is also an indication that Korea s international status has risen to that extent. And this is also the potential for South Korea to lead cooperation with the international community for various support to North Korea, including the health care sector. South Korea should promote organic cooperation among various actors at home and abroad for humanitarian activities toward North Korea. In particular, South Korea should promote principled aid to North Korea, and should diversify detailed support areas to reflect North Korea s needs. Above all, the South Korean government should prepare laws and systems and make diplomatic efforts to ensure that humanitarian activities against North Korea can be carried out even in political and military situations between the two Korea.

보건의료 분야 디지털 헬스 관련 정책의 국제 현황 조사

조경온(Kyeongon Cho),김광준(Kwang Joon Kim) 대한약학회 2023 약학회지 Vol.67 No.2

This study aims to investigate the international status of digital health policies of government and pharmaceutical association in major developed countries including USA, EU, and Australia. The study conducted data research with focus on the ‘digital health care system’ and examined the policies of each country as well as the policy trends of pharmacist societies. The results indicated that major countries in the USA, EU, and Australia regions are building a data-centered digital health ecosystem. The digital health policies of pharmaceutical associations in major developed countries aim to enable pharmacists to participate and contribute to building a data-centered digital health ecosystem in line with government-led policies. The study’s results are considered to be essential data for adapting to the digital era in the pharmaceutical industry.

일제강점기 강원도의 보건 의료와 급성 전염병에 관한 분석

이규원 ( Lee Kyu Won ) 강원대학교 강원문화연구소 2021 강원문화연구 Vol.43 No.-

본고에서는 일제강점기 강원도의 보건 의료 제공과 급성 전염병 유행 상황을 일제 당국이 남긴 통계 자료를 통하여 분석하였다. 강원도 지역은 인구 대비 도립의원 병상 수, 병원 수, 의료 관계자 수가 상대적으로 크게 부족하여 보건의료의 측면에서 열악하였지만, 강원도 거주 일본인은 오히려 큰 수혜를 입었다. 급성 전염병에 관하여 조선총독부의 통계에는 조선인의 상황이 제대로 집계되어 있지 않아 조선인의 실상을 파악할 수 없다. 재조 일본인의 급성 전염병 사망률을 분석한 결과, 조선은 일본 본토의 4배 수준이었고, 강원도는 조선에서 급성 전염병, 특히 콜레라를 제외한 소화기계 전염병의 위협이 가장 큰 지역 중 하나였다. 그러나 강원도에서는 식민지 당국의 방역과 위생 관련 조치가 상당히 미흡하였으며, 조선인의 상황은 일본인보다 훨씬 더 심각한 수준이기 때문에 다른 지역보다 악조건이었다고 짐작할 수 있다. 의료와 방역에 관한 한, 소위 식민지 근대화론은 성립하지 않는다. This paper analyzes the health care and the circumstances related to the acute epidemics in Gangwon-do during the Japanese colonial period through statistical data left by the Japanese authorities. While the number of hospital beds, hospitals, and medical personnel was relatively deficient in proportion to the rate of the population, which caused poor health and medical care, the Japanese residents in Gangwon-do actually benefited greatly. The Japanese Government-General of Korea did not accurately collect data on the situation of Korean people as for acute infectious diseases, so it is impossible to grasp the reality of Koreans at that time. Through analysis of the mortality rate from acute epidemics among Japanese residents in Korea, this paper found that the mortality rate in Joseon was four times higher than that in Japan, and Gangwon-do was one of the regions with the greatest threat of acute epidemics, especially when it comes to intestinal ones excluding cholera. Therefore, it can be inferred that in Gangwon-do, the measures of the colonial authorities related to the prevention of acute infectious diseases and hygiene were quite insufficient, and the situation of Koreans was much more serious than that of Japanese. In terms of medical care and the prevention of epidemics, the so-called colonial modernization theory is a kind of illusion.

Partnership between Health and Social Care in the New Labour Government: Critical review of the policies in England

Yong Ho Chon,Keun Hong Kim 한국사회복지정책학회 2007 사회복지정책 Vol.31 No.-

지방자치단체 감염병 담당자들의 메르스 위기대응 인식과 경험 탐색

이수경(Su Kyoung Lee),이윤수(Yun Su Lee),조성일(Sung-il Cho) 한국보건교육건강증진학회 2018 보건교육건강증진학회지 Vol.35 No.3

Objectives: The objective of this study is to gain a qualitative insight into provincial, metropolitan and local infectious disease emergency responders’ (IDERs’) response experiences in the 2015 Middle East Respiratory Syndrome (MERS) outbreak in South Korea. Methods: The focus group interview (FGI) method was employed to collect qualitative data from 4 different focus groups of 25 representative registered IDERs over the period from Dec. 2016 to Jan. 2017. The stratified sampling method was used to select them among different ages, genders, job positions, job series and job groups of 259 IDERs. All interviews were recorded and transcribed in verbatim, and analyzed according to the qualitative thematic analysis method using NViVO software. Results: The process of being reluctant to be positioned as an IDER or at an IDER-related unit or team was based in four subcategories. The overriding theme was experiencing differences between the regulatory system called `rotation job`, which is a characteristic of civil servants` organizations that have difficulty in maintaining professionalism and persistence of work, and the actual reality of the `new respiratory infectious disease` crisis spread. In the case of massive cases caused by the spread of infectious diseases, the imbalance of powers and responsibilities of local government infectious disease officials, fear of infectious diseases and fear framing are problems. Conclusions: The insights of the study indicate the need to identify the following priorities for gradual, practicable policy reforms that would require the involvement of the central government. The regulatory limitations of current system with a shortage of human and material resources pushed the participants to experience discrepancies between the required regulation and the reality. Additional research could contribute more exemplars to support changes.

해방기(1945-1948) 주요 정치집단과 미군정의 의료보장체계 구상

전예목,신영전 대한의사학회 2022 의사학(醫史學) Vol.31 No.1

The liberation period in Korea was when creative imagination and various debates existed about plans for political, economic, and social systems. Among them was the debate over the national health security underlying the social safety net. Although the US influenced the Korean health security after liberation, major political groups on the Korean peninsula also expressed various opinions. However, previous studies have shown little interest in national health security, which operates the public health and medical care systems. To overcome these limitations, this study focuses on the ideas on national health security presented by major political groups, analyzing the reply proposal of “Jŏnpyŏng” and the health care proposal of the US military government, which has not been reviewed before. The opinions of major political groups including the right-wing Im-hyŏp and left-wing Min-chŏn diverged on national health security issue regarding insurance coverage, measures to secure financial resources, items of insurance benefits, and measures to stabilize the supply and demand of medical personnel. The claims of the US military government can be understood by “Labor Problems and Policies in Korea (Korean Subcommittee),” “Korean Labor Report (Stewart Meacham),” and “Proposed Political Platform Provisional Korean Democratic Government (Sub-commission #2).” The major political groups and the US military government agreed on the need for social protection against death, old age, disability, disease, injury, and unemployment. All of them claimed national health security, in which the roles of the private sector and the government were mixed, should be gradually introduced. The major political groups, in particular, proposed to (1) set workers as beneficiaries of insurance, (2) share financial resources jointly among the state, employers, and workers, and (3) promote the expansion of the number of doctors and medical institutions and prefer cooperative operations of the hospitals established in small administrative units. This paper argues that the ideas on national health security during the liberation period did not completely deviate from the global trend immediately after World War II when countries tried to expand the number of people covered by national health security and strengthen its coverage. Although these ideas were not fully reflected in the Constitution of 1948, it is significant in that the Constitution codified for the first time the state’s responsibility for those who have no ability for living due to their health conditions.