『保健医療科学』 2022 第71巻 第4号 p.324-334（2022年10月）
特集 ： 新型コロナウイルス感染症の教訓―パンデミックにいかに対峙し何を学んだか― ＜解説＞
新型コロナウイルス感染症の医療提供体制の振り返りと将来展望 ―神奈川県の取り組みを中心に―
阿南英明
神奈川県庁 / 藤沢市民病院
Review and future prospects of the medical system for COVID-19: Focusing on the efforts of Kanagawa Prefecture
ANAN Hideaki
Kanagawa Prefectural Government/ Fujisawa City Hospital
抄録
本邦の医療構造の特徴として，高度複雑な病態に対応できる実質的な急性期病床はOECD諸国に比して少なく，医療職の配置も相対的に少ない. また，世界で最も高齢化が進む本邦では高齢者対応や長期慢性病態への対応を重視して体制構築されてきた. 強制的に医師や看護師を従事させる仕組みもなく，感染症パンデミック対応に苦慮してきた背景がある. 2020年2月に発生したダイヤモンド・プ リンセス号でのアウトブレイク対応の教訓に基づいて，重症度や医療需要から患者を分類し各々受け皿となる施設を役割分担する体制が整備された. しかし，外来機能の提供，自宅療養患者や高齢福祉施設内の患者の治療介入，COVID-19併存疾患への医療提供など，包括的な過不足ない医療提供体制が十分に構築できていなかった. 感染拡大期に急激に増える入院需要に対して病床確保の課題があり，物理的な病床の確保以外に，フェーズに応じた病床拡大縮小に関する協定締結，効率的な病床運用の ために，入院基準の見直しや後方受け入れ病床の確保，自宅療養者の健康観察に地域医療が参画する 仕組みなどが打ち出された.しかし，徐々にウイルスの特性が判明し，ワクチンや治療法が導入された後でも，種々ある疾病の中の一部としてCOVID-19を位置づけることができず，COVID-19診療に偏重したという弊害，高齢者施設への医療介入の困難性，臨時医療施設や入院待機ステーションなどの運営の困難性，医療情報を共有する基盤整備の遅れなどの多くの課題が表出した.
コロナの体験から得られた教訓と将来へ向けた対策として，人々の健康維持が困難になるような「有事」に対して，即座に対応できる体制構築を行う健康危機管理の考え方を基軸に検討する必要がある. 国から自治体，医療現場や保健所に至る階層化された組織体制と明確な役割や指示命令系統構築，人材育成，病床確保などの医療提供体制の在り方，さらには資機材や医薬品，ワクチンの確保などグローバルな観点で医療提供を確保する「健康安全保障体制」の構築が不可避である. 今回のパンデミックで課題となった情報共有基盤整備と国民とのコミュニケーションのあり方は保健医療体制とは異なる専門性を交えた取り組みも求められている.
キーワード : 健康危機管理，安全保障，情報共有基盤，高齢者
Abstract
One characteristic of the healthcare structure in Japan is that, compared with other Organization for Economic Co-operation and Development (OECD) countries, fewer substantive acute phase beds are available to handle highly complex pathologies, and there are fewer assigned healthcare personnel. In addition, Japanʼs population is aging at one of the highest rates in the world, and its healthcare system has been structured with an emphasis on treating the elderly and long-term chronic conditions. It has traditionally also lacked a mechanism to force doctors and nurses to engage in specific practices, and has struggled to deal with infectious disease pandemics. Based on the lessons learned in handling the outbreak on the Diamond Princess cruise ship that occurred in February 2020, a system for dealing with infectious disease pandemics has been developed. However, a comprehensive and justly proportional system for the provision of healthcare, including the provision of outpatient services, medical interventions for home care patients and patients in elderly welfare facilities, and healthcare provision for patients with comorbid COVID-19 has yet to be sufficiently established. As ensuring hospital beds when there is a rapidly increasing demand for hospitalization during the spread of infections remains an issue, measures have been taken such as the conclusion of agreements related to ensuring beds, a review of hospitalization criteria and ensuring beds with “rearward” acceptance, and the participation of community medicine in health observations of home care patients. However, while the characteristics of the virus were gradually becoming clear, and vaccines and treatment methods were being developed, COVID-19 could not be positioned as one among the myriad types of disease, and many problems surfaced.
As lessons from the experience of COVID-19 and measures for the future, investigations are needed based on the thinking of health risk management. It is therefore necessary to prepare and develop systems for dealing immediately with emergencies in which maintaining peopleʼs health may become difficult. The implementation of a health security system that involves national to local governments, which already have the best healthcare provision systems, is absolutely essential. The information sharing infrastructure and how to best communicate with citizens have been issues in this pandemic, and efforts that include expertise from outside the healthcare system are needed.
keywords : health risk management, security, information sharing infrastructure, senior citizen
