일차보건의료의개념과발전방향 2009 년 2 월 13 일 한림대학교의과대학 최용준 1. 논의범위. (primary health care) (primary care)...,.., ). 2) 2. 일차보건의료 가. 개념과그형성 (WHO, 1978) 2000,...

일차보건의료의개념과발전방향 2009 년 2 월 13 일 한림대학교의과대학 최용준 1. 논의범위 (primary health care) (primary care),, 1) 2) 2. 일차보건의료 가. 개념과그형성 (WHO, 1978) 2000, Ⅵ. 일차보건의료는실용적이고과학적으로건전하며사회적으로수용가능한방법과기술에바탕을둔필수적보건의료서비스다. 일차보건의료는지역사회의개인과가정이충분한참여를통해보편적으로접근할수있는것이어야하며지역사회와국가가자조와 1) http://www.chsc.or.kr 2) 1/13

자결의정신아래발전의매단계에서비용을감당할수있는수준이어야한다. 일차보건의료는국가보건의료체계의중심기능이자주요초점인필수구성요소다. 또지역사회의사회경제적발전전반에필수적인구성요소이기도하다. 일차보건의료는사람들이생활하고일하는곳과가장가까운데에서보건의료를제공한다. 개인과가족, 지역사회가국가보건의료체계와접촉하는첫번째수준이며지속적인보건의료과정의첫째요소다. Ⅶ. 일차보건의료는, 1. 한국가와지역사회의경제적상태와사회문화적 정치적특징을반영하고이로부터서서히발전한다. 사회과학과생의학, 보건의료관리연구의결과와공중보건의경험을응용하는것을바탕으로삼는다. 2. 지역사회의주요건강문제를다루며그에맞게건강증진과예방, 치료, 재활서비스를제공한다. 3. 최소한다음을포함한다. 주요건강문제와이를예방하고관리하는방법에대한교육, 식량공급과적절한영양의증진, 안전한식수와기본위생서비스의충분한공급, 가족계획을포함한모자보건서비스, 주요감염성질환에대한예방접종, 지역풍토병예방과관리, 흔한질환과손상에대한적절한치료, 필수의약품제공. 4. 보건의료부문에더하여, 국가와지역사회의발전에관련된모든부문, 특히농업, 축산업, 식품, 산업, 교육, 주택, 공공사업, 통신과기타부문을포함한다. 일차보건의료는이모든부문의조화로운노력을요구한다. 5. 지역사회와국가, 기타이용가능한자원을최대한활용함으로써, 지역사회와개인의최대한의자조와, 일차보건의료의기획과조직, 운영, 관리에대한참여극대화를요구하고장려한다. 이를위하여적절한교육으로지역사회의참여능력을개발한다. 6. 통합적이고기능적이며상호지원하는의뢰체계에의해유지되어야한다. 그럼으로써모든이들을위한포괄적보건의료를지속적으로개선할수있고가장필요가큰이들에우선순위를둘수있다. 7. 환자를의뢰할경우가있는지역수준에서, 필요한경우전통의료시술자뿐아니라, 의사와간호사, 조산사, 의료보조원, 적절한경우지역사회활동가를포함한보건의료종사자에의존한다. 이들은보건의료팀으로일하고지역사회의건강필요에대응할수있도록사회적으로나기술적으로적합하게훈련되어야한다., (Vuori, 1985)., 3, (selective) (Cueto, 2004). 2/13

,, (primary medical care),,,,,,,, (Halfdan T. Mahler) (Cueto, 2004).? 나. 원천 3) 1950~60, 1949 1957 1960 (Litsios, 2002). 1952 (basic health services), (Socrates Litsios) 1937 (Litsios, 2002). Christian Medical Commission (CMC) (Cueto, 2004; Litsios, 2004). CMC 1960 (World Council of Churches) 3) 3/13

1970 Contact 1974 CMC WHO, 1950, (John Bryant), (Carl Taylor), (Kenneth W. Newell) WCC WHO (barefoot doctors) 1960 (1964~1976),,,. 1951 1957 20 1960 3, 6, 1 (Weiyuan, 2008). WHO 1973 1988, (Litsios, 2002). 다. 일차보건의료를둘러싼쟁점 (Cueto, 2004) (selective primary health care) (Robert S. McNamara) (Bellagio) (Kulia Walsh) (Kenneth S. Warren) GOBI-FFF 4), UNICEF 4) Growth monitoring, oral rehydration, breast-feeding, and immunization; food supplementation, female literacy, and family planning. 4/13

,, ( ) 3. 일차의료 가. 개념과그형성 (Barbara Starfield) (Dawson report) (Starfield, 1998). (National Health Insurance) 8 1920 (primary health center) (secondary health center), (teacing hospitals) (regionalization) 1978, 2,,, (Vuori, 1985). 나. 일차의료와일차보건의료 1 (Vuori, 1985). (self-reliance),,, 5/13

그림 1. 일차진료에서일차보건의료로의변화 ( 출처 : Vuori, 1985), (Starfield, 1998).,, (Institute of Medicine, IOM) (Donaldson et al., 1996). 일차의료는대부분의보건의료필요해결을책임지는임상의사가제공하는통합적이고 접근성이높은보건의료서비스를말한다. 이임상의사는환자와지속적인관계를발 전시키고가족과지역사회맥락에서활동한다. (Lee et al., 2007). 일차의료란건강을위하여가장먼저대하는보건의료를말한다. 환자의가족과지역사회를잘알고있는주치의가환자-의사관계를지속하면서보건의료자원을알맞게모으고조정하여주민에게흔한건강문제들을해결하는분야이다. 일차의료기능을효과적으로수행하기위해서는여러분야보건의료인들의협력과주민의참여가필요하다. 6/13

4. 일차의료에바탕을둔보건의료체계의개혁 2000,,, (evidence-based health care) HEN (Health Evidence Network) (Helath Evdence Network, 2004). 일차의료수준이높을수록인구집단의건강결과가좋았다. 일차의료의이용가능성이높을수록만족도가높고비용이덜들었다. 선진국에서는전문의료정향성이강할수록접근성의불평등이컸다. 후진국에서는일차의료정향성이강할수록형평적이고접근성이높았다. 전문의료와비교시비용이덜들고만족도가높으면서질이나쁘지않았다. 이차의료에서일차의료로전환시비용효과적이었다. 일차의료확대가늘비용절감을의미하는것은아니다. 일차의료확대는종종미충족필요의충족, 접근성의개선, 서비스이용의증가등을동반하기때문이다. (Starfield et al., 2005). 일차의료는필수서비스에대한접근성을향상시킨다. 일차의료는임상의료의전반적인질적수준을향상시킨다. 일차의료는상대적으로예방을강조하는경향이있다. 일차의료는건강문제의조기발견과치료에유용하다. 일차의료는질병보다는환자에초점을맞춘다. 불필요하거나부적절한전문의료이용을줄인다. 7/13

5. 몇가지과제 가. 논의의전제 나. 몇가지과제 6. 참고문헌 Cueto M. The origins of primary health care and selective primary health care. Am J Public Health. 2004. Donaldson JS, Yordy KD, Lohr KN, Vanselow NA. editors. Primary care: America's health in a new era. Washington, DC: National Academy Press; 1996. Health Evidence Network. What are the advantaged and disadvantages of restructuring a health care system to be more focused on primary care services? Copenhagen (Denmark): WHO Regional Office for Europe; 2004. Lee JH, Choi YJ, Volk RJ, Kim SY, Kim YS, Park HK, Jeon TH, Hong SK, Spann SJ. Defining the concept of primary care in South Korea using a Delphi method. Fam Med. 2007 Jun;39(6):425-31. Litsios S. The Christian Medical Commission and the development of the World Health Organization's primary health care approach. Am J Public Health. 2004 Nov;94(11):1884-93. Litsios S. The long and difficult road to Alma-Ata: a personal reflection. Int J Health Serv. 2002;32(4):709-32. Starfield B. Primary care: balancing health needs, services, and technology. 2nd ed. New York: Oxford University Press; 1998. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. Vuori H. The role of the schools of public health in the development of primary health care. Health Policy. 1985;4(3):221-30. Weiyuan C. China's village doctors take great strides. Bull World Health Organ. 2008 Dec;86(12):914-5. 8/13

World Health Organization, United Nations Children's Fund. Report of the International Conference on Primary Health Care: Alma Ata, USSR, 1978 Sep 6-12. 7. 문헌소개 가. 일차보건의료의형성 Cueto M. The origins of primary health care and selective primary health care. Am J Public Health. 2004 Nov;94(11):1864-74. Litsios S. The long and difficult road to Alma-Ata: a personal reflection. Int J Health Serv. 2002;32(4):709-32. Cueto Litsios 1978 10,, 나. 일차보건의료의과거, 현재, 미래 World Health Organization, United Nations Children's Fund. Report of the International Conference on Primary Health Care. Alma Ata (USSR); 1978 Sep 6-12. World Health Organization. The world health report 2008: primary health care now more than ever. Geneva: World Health Organization; 2008. (Almaty, ) 30 다. 일차의료교과서 Starfield B. Primary care: balancing health needs, services, and technology. 2nd ed. New York: Oxford University Press; 1998. 9/13

라. 일차의료의성과에관한근거 Health Evidence Network. What are the advantaged and disadvantages of restructuring a health care system to be more focused on primary care services? Copenhagen (Denmark): WHO Regional Office for Europe; 2004. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. HEN 마. 만성질환관리 Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;74(4):511-44. Nolte E, Knai C, McKee M. Managing chronic conditions: experience in eight countries. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies; 2008. (Observatory Studies Series; no. 15)., (Wagner) (chronic care model) European Observatory 8 care journey 10/13

부록,, 1978 9 6-12 1978 9 12,,,,,,,,,,,, (New International Economic Order),,,,, 2000, 11/13

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(WHO)/ (UNICEF) 2000,,,,,,,,,,, (WHO) (UNICEF),,,,,,,,,, 13/13