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국민의료에 관한 연구 : 서울시민의 상병(傷病) 및 의료에 관한 종합적 연구

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 (A) comprehensive study on the health needs and health care in Seoul 
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During the last decade since the liberation in 1945, Korea, unfortunately, has not had enough political and social stability to study her nationwide health needs and the problems in its care. Most of the administrative and educational measures taken in the field of public health and medical care have been temporary emergency one : or because of traditional inertia, blindly imported foreign systems have been followed. In order to attain our final goal of providing best-quality comprehensive medical care for all people who need it and at minimum cost : We need an adequate and proper plan, set up on the basis of understanding the health needs at both local and national levels. The principal purpose of this study, therefore, were to obtain the information concerning the following aspects of health and health care through the study of the citizens of Seoul : 1. The measurement of health needs. 2. The extent of unmet need for medical attention. 3. The cost of medical care. 4. The attitudes of the folks towards illness, doctors and other healers, and health facilities available. 5. An analysis of socio-economic and cultural anthropologic factors. The source of information for this study consists of a two-stage systamatic sample, namely, 933 households consisting of 5,159 persons, a representative cross-section which is about one three-hundredth of all households (281, 601) and of the total population of Seoul (1,574,868) as of September 1, 1955. For the first stage, the sampling unit was the "Pan", which is the smallest cluster of households, and the sampling rate was 1/100 ; and for the second stage, the sampling unit was the household, and the rate was 1/3. In this sample, the loss rate was only 0.5%, which is extremely lower than that in other countries. Also, we were able to see a relatively constant sampling ratio between the various characteristic variables, too. Therefore, the data obtained from this sample can be assumed to represent the native population reasonably well. In order to exclude every possible bias, well-trained non-medical senior women college students were used as the interviewers. The form used consisted of the open-end questionaire, which was revised after a pilot study. For the determination of health needsm, the method of symptom-approach using 40 kinds of symptoms was used. The questionaire asked about the experiences during the preceding 6 months. As the survey was carried out during the one-month period from August 1, 1956, the data obtained from this study are the experiences of Seoul citizens from February 1 to July 31, 1956 ; 86.3% of those questioned were female heads of housholds. The findings of the survey are as follows : 1. It was found that 63.6% of Seoul citizens had no symptoms ; 36.4% of Seoul citizens had one or more symptoms during the 6-month period, averaging 1.9 symptoms during the half-year. Therefore, the morbidity incidence rate was 74 symptoms per 100 citizens. The most prevalent symptoms were related to diseases of the digestive system, nutritional, and parasitic infection. The frequency rate of this particular disease group of digestive system is much higher than that obtained in the study of hospital cases. The morbidity rate of females was more than two times that of males in the age groups of 15-44. In the male, the morbidity incidence was lowest in the age groups of 15-24 and highest in the age group of 65 and over ; however, in the female, the incidence was lowest in the age group of 5-14, and highest in the 45-64 age group. There were significant differences in the morbidity rate among the different socioeconomic family groups, those low in income and in educational standards having a higher rate ; the more overcrowded the living accommodation, the higher was the rate. Farmer, unemployed, and daily worker groups had higher morbidity rate than other occupational groups. 2. Only 42.8% of their symptoms did Seoul citizen regard as being and illness, and for 57.2% of their symptoms, medical care was not sought. Particularly, where repeated or frequent bleeding gums, poor vision, unexplained loss of weight, repeated nose bleeds, continued loss of appetite, unexplained tiredness (reqularly), persistant cons pation, persistant pains in the joints were the eminent symptoms ; more than 70% of these were not regarded by the people as abnormal conditions demanding medical care. This shows that increasing the number of medical personnel or the facilities for medical care will do little to improve the general health and the medical care of the people unless there is adequate health education for the people. If we make a similar survey at the rural level and compare the results with this data, we can easily confirm the assumption that the demand rate for medical care in rural communities will be much lower than that in Seoul, though the people in rural areas might have higher morbidity rates than that in Seoul. 3. The loss of work or other regular activity due to illness during the period of 6 months was 138 days per 100 persons, which was incurred by the 5.4% of entire citizen it was 124 days per 100 males and 152 days per 100 females. Among the various age groups, the lowest rate was in the 5-14 age group for both sexes, and the highest rate was in the 45-64 age group for males and in the over 65 age group for females. 4. Only 44% of the demand for medical care was met ; 15% of the demand was unmet, while the rest (41%) is uncertain. Consequently, it could be said that only one fifth of health needs was cared by medical personnel and related facilities. (Whole symptoms × 42.8/100 × 44.2/100 = 18.0). Among those whose symptoms were not cared for, 78% claimed economic difficulty as their reason, such as "no money" or "too expensive". This shows that the second inportant things to do for the inprovement of health and medical care is to provide some provision for the payment of the cost of medical care, so that every patient can get what he or she at any time and without delay or postponement. This might well be done by reorganizing existing medical personnel, facilities, and medical care expenses. 5. The total cost of medical care during the 6 months was HW 10,700 per family (including no-patient families), and HW 2,000 per person. Twice this cost of medical care is 7.2% of the average annual family income (HW 300,000) of Seoul City. In general, many factors, such as low income, high morbidity in the community, a higher demand for medical care account for the high ratio of medical cost to income. Therefore, it is presumed that in our rural communities, the cost of medical care would surpass 7.2% of the average annual family income. Only 1/1,000 of citizen incurred as much as a half of entire medical costs, and 1/40 of citizen incurred 87% of total charges while upon 39/40 of citizen fell 13% of the total charges. Low income families spent a greater proportion of their incomes on the costs of sickness than did the well-to-do and the wealthy. The mean costs and the median cists per illness paid to medical doctors was HW10,300 and HW1,500 respectively, while that paid to herb doctors was HW16,100 and HW1,700 respectively. The high mean cost of HW23,400 paid to hospitals, while its median is only HW1,000, is due presumably to serious cases coming to the hospital. But it is rather ridiculous that mean costs paid to specialists should be less than half that paid to general practitioners. It is also surprising that they paid a mean of HW9,800 and a median of HW2,500 for moxa and acupuncture compared with a mean of HW9,400 and a median of HW1,500 for general practitioner. These phenomena show that there is much waste in the medical expenditures of the people. The analysis of medical costs according to payment to doctors, hospitals, and for drugs, etc.,was rather difficult to make since the current accounting system in this country does clearly differentiate these categories. 6. The responses given to interviewers regarding what was believed to be the cause of whether due to demos, curse, witchcraft, sin, and fear or fright, were frank and revealing ; in general, those questioned born in the southern provinces of Korea gave more superstitious answers than those born in the northern provinces of Korea. Among the different religious groups, Christians gave the least superstitious answers. 7. Regarding the choice of healer, 83.4 of those questioned preferred medical doctors ; of these 71.9% were in general practice, 5.9% were specialists, 0.9% were foreign doctors, 4.7% denoted hospitals. Only 12.7% preferred herb-doctors ; the rest chose other healers or patent drugs. However, only 71.5% of them actually visited medical doctors and as many as 14.5^ of them visited herb-doctors, and the number visited drugstore or superstitious healer increased to two and a half times of the number they wanted, Such a phenomenon might be interpreted as due to the belief that herb-doctors charge less than medical doctors in general. But actual figures reveal the opposite, for 73.0%, 22.3%, and 4.7% of the cost paid to healers were to medical doctors, herb-doctors, and other healers respectively. Facts already mentioned reveal that herb-doctors charge more per illness than medical doctors on an average. The higher the educational level of the head of the household, whether male or female, the stronger the choice for medical doctors. Administrative warkers, specialistic and technical workers, and sales business groups had stronger choice for medical doctors than the other occupational groups, christian families had stronger choice for medical doctors than the other religious groups. 8. Inquiring what kind of treatment were given at the clinic of various healers visited, it is surprising to find that consultation, injections, dressings, prescription and even operation were frequently done at drugstores, and injections by herb-doctor. Mean duration and median duration of care given per illness was 13.1 days and 2.9 days respectively in general ; however that of cared by herb-doctors were the longest being 17.0 days and 4.4 days. About a half of patients had treatment lasting three days or less and 14% of patients spent one month or longer for the care of their illness. 9. Very few seems to have their own family doctor. The most prevalent reason for their choosing healer is nearness and convineance, and hearing good rumour. More than 30% of the patients changed their doctor or healer during treatment. The primary reason given for their change of healar was the "effectiveness of the treatment." ; other reasons such as "expensive charge", "unkindness" or "recommendation by family doctor" had little role in causing them to change healers. The only one exception was seen in the case of one hospital where the complaint of unkindness was decisive. Random advertisement of healers and drugs, and free also of any drugs without doctor's prescription should be controled ; and the competition for patients between general hospitals and general practitioner should be abolished. 10. Relatively few interviewees could indicate why they like or dislike a doctor or herb-medicine was preferable for such vague conditions as "cold", "women's disease", "Internal disease", "General malaise", etc. About 59% of the interviewees commented favorably on "tonics" ; and actually, more than 5% of sampled familieg used "tonics" costing an average HW15,400 during the period, which is 7.7% of entire annual expenditures from medical care. The family groups higher in income used "tonics" more frequently than the lower income groups. 11. Only 54.4% of interviewees recognized distinction between a general hospital and a doctor's clinic. Those living in Songpuk-Ku, and Chung-Ku knew this distinction, whereas those living in Yong-wan-Ku and Yondongpo-Ku had a relatively poor understanding of a general hospital . The higher the educational standard of the interviewees, the better their understanding of the general hospitals were "excellent medical doctors", "good facilities", "cheap cost", and "clean". On the other hand, the main unfavorable comments were "unkindness", and "keeps us waiting". Only 22.4% of respondents ever heard the word "health center". Most people generally had poor understanding about the location, function, financing and administration of health centers. The higher the educational standard of the female heads of households, the better their knowledge about health centers. Only 5.7% of responding families ever visited to health center ; the higher in income and in educational standards, the higher was the rate. 12. Regarding medical insurance, 45.5% of interviewees gave favorable opinions, while 24.2% had no opinions and 30.3% had adverse opinions. Regarding a national health service, 40.9% responded favorably, 26.9% were indifferent, and 32.2% responded adversely. The group lowest in educational standards and in income had favorable respond to a national health service system.
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