중·저소득 국가에 대한 독일의 건강보험제도의 교훈

One hundred and eighteen years of the German health insurance system: are there any lessons for middle- and low-income countries?

Till B.arnighausen*, Rainer Sauerborn

Department of Tropical Hygiene and Public Health, Medical School, University of Heidelberg, INF 324, 69120 Heidelberg, Germany

o 배경

¡ 많은 수의 저소득·중소득 국가들은 사회건강보험(Social Health Insurance, SHI) 도입을 고려하고 있음.

¡ SHI는 1883년 독일에서 처음 도입되었으며, 도입 이후 지금까지 독일 시스템을 분석함으로써 다른 국가들을 위한 교훈을 도출할 수 있음.

o 결론

¡ 소규모의, 비공식적, 자발적 건강보험제도를 활용하여 재정 운영과 재정 견고성(solidarity)에 대해 학습할 수 있으나, 전국민에 대한 보장을 달성하기 위해서는 정부는 이들 제도를 공식화하고 강제할 원칙을 도입해야 함. 일단 일부 인구를 대상으로 건강보험이 도입되면 다른 지역과 인구집단에 대한 점진적 확대가 용이해짐.

¡ SHI의 지속가능성을 확보하기 위해서는 변화하는 요구, 가치, 경제적 상황에 맞추어 적절한 복리후생제도(benefit package)가 뒤따라야 함.

¡ 다원적(pluralistic) SHI제도에서 재정이 병합(merge)된다면 위험을 분산시키는 것이 가능함.

¡ 자치(self-governance) 방식은 국가적 규제 또는 시장의 규제를 대신하여 보건시스템을 분권화/민주화 시키고 안정성과 지속가능성을 높이는 방법이 될 수 있음.

¡ 행위별수가제 시스템 내에서 정치적 압력 또는 기술적 수단(technical mean)으로 비용 상승의 원인이 되는 공급자의 행동을 규제할 수 있다면 비용을 절감할 수 있음.

---

Soc Sci Med. 2002 May;54(10):1559-87.

One hundred and eighteen years of the German health insurance system: are there any lessons for middle- and low-income countries?

Bärnighausen T1, Sauerborn R.

Author information

Abstract

A number of low and middle income countries (LMICs) are considering social health insurance (SHI) for adoption into their social and economic environment or striving to sustain and improve already existing SHI schemes. SHI was first introduced in Germany in 1883. An analysis of the German system from its inception up to today may yield lessons relevant to other countries. Such an analysis, however, is largely lacking, especially with regard to LMICs. This paper attempts to fill this gap. For each of the following lessons, it considers if and under which conditions they may be of relevance to LMICs. First, small, informal, voluntary health insurance schemes may serve as learning models for fund administration and solidarity, but in order to achieve universal coverage government action is needed to formalise these schemes and to introduce a principle of compulsion. Once compulsory health insurance exists for some people, incremental expansion of coverage to other regions and social groups may be feasible to achieve universality. Second, in order to ensure sustainability of SHI, the mandated benefit package should be adapted incrementally in accordance with changing needs, values and economic circumstances. Third. in a pluralistic SHI system equity, as well as risk pooling and spreading, can be enhanced if funds merge. The optimal number of funds, however, will depend on the stage of development of the SHI system as well as on other objectives of the system, including choice and competition. A risk equalisation scheme may prevent the adverse effects of risk selection, if competition between insurance funds is introduced into the system. Fourth, as an alternative to both state and market regulation, self-governance may serve as a source of stability and sustainability as well as a means of decentralising and democratising a health care system. Finally, costs can be successfully contained in a fee-for-service system, if cost-escalating provider behaviour is constrained by either political pressure or technical means.