1963년부터 논쟁이 되어온 의약분업은 오랜 기간 동안 시행되지 못하고 표류하다가 1998년 김대중정부에 의해 본격적으로 추진되었다. 그리고 2년 반 동안의 격렬한 논쟁과 의료대란을 거치면서 2000년 7월부터 실시되었다. 의약분업정책은 과거의 보건의료정책이 정부와 이익집단 양자간에 의해 결정되었던 방식과는 달리 시민단체가 정책결정과정에 적극적으로 참여하였다. 시민단체의 참여로 의약분업정책은 공익성을 띄게 되었으며 국민과 여론의 관심을 높일 수 있었다. 그리고 이익집단의 활동을 견제하면서 의약분업정책을 추진할 수 있도록 정부에 힘을 실어주었다. 더욱이 보건의료 정책과정에 국민이 간접적으로나마 참여할 수 있는 ...
1963년부터 논쟁이 되어온 의약분업은 오랜 기간 동안 시행되지 못하고 표류하다가 1998년 김대중정부에 의해 본격적으로 추진되었다. 그리고 2년 반 동안의 격렬한 논쟁과 의료대란을 거치면서 2000년 7월부터 실시되었다. 의약분업정책은 과거의 보건의료정책이 정부와 이익집단 양자간에 의해 결정되었던 방식과는 달리 시민단체가 정책결정과정에 적극적으로 참여하였다. 시민단체의 참여로 의약분업정책은 공익성을 띄게 되었으며 국민과 여론의 관심을 높일 수 있었다. 그리고 이익집단의 활동을 견제하면서 의약분업정책을 추진할 수 있도록 정부에 힘을 실어주었다. 더욱이 보건의료 정책과정에 국민이 간접적으로나마 참여할 수 있는 참여민주주의 가능성이 열렸다는 측면에서 긍정적으로 평가할 수 있다. 그러나 의약분업정책은 ‘진료는 의사에게 조제는 약사에게’라는 간단한 구호와는 달리 우리나라의 전반적인 의료체계와 연관되어 있다. 그리고 의약분업정책을 결정하기 위해서는 우리나라 의료보험 제도와 제약산업, 의료전달체계 등 의료시스템에 대한 이해와 의료와 약에 대한 전문적인 지식이 필요하다. 그런데 이러한 전문성이 부족한 다수의 시민단체 대표가 참여하여, 정책참여자들간의 합의가 이루어지지 않은 상태에서 성급하게 밀어붙인 의약분업정책은, 의료계와의 갈등을 심화시키고 의료대란을 야기시켰다. 그리고 의약분업시행 이후 건강보험재정은 악화되었으며, 국민들의 불편감은 증가되고, 임의조제는 여전히 계속되며, 의약분업은 취약계층의 의료이용을 저하시키는 결과를 가져왔다. 본 연구는 의약분업정책에 대한 이러한 문제의식을 가지고 의약분업 정책형성 과정을 정책의 흐름과 변화에 따라 네 단계(제 1기 : 정책의 시동기, 제 2기 : 정책의 지연기, 제 3기 : 정책협력기, 제 4기 : 정책갈등기)로 구분하였다. 그리고 각 시기별로 의약분업정책의 결정과정을 정책네트워크모형에 의해 분석하였다. 정책네트워크을 통해 의약분업정책을 분석한 이유는 의약분업정책의 주요 참여자인 정부, 이익집단, 시민단체가 정책결정권을 비교적 동등하게 공유하였으며, 정책네트워크가 어떤 유형을 적었느냐에 따라 그리고 누가 정책결정에 주도적인 역할을 하였느냐에 따라 정책내용이 변화하였기 때문이다. 따라서 정책참여자와 이들의 상호작용에 의해 변화하는 정책네트워크유형이 정책내용에 어떻게 영향을 미쳤는가를 분석하였다. 분석결과 의약분업정책의 주요 참여자는 보건복지부, 의사협회, 약사회, 시민단체이며 형성단계에 따라 대통령, 정부여당과 야당, 국회의원, 언론 등이 참여하였다. 제 1기에서는 보건복지부가 의약분업추진을 위하여 구성한 「의약분업추진협의회」에 의해 정책이 결정되었으며 제 2기에서는 「의약분업추진협의회」의 의약분업안을 반대하며 의료계와 약계가 의약분업실시를 지연시키기 위한 정책활동을 하였다. 그리고 「국민회의」에 의해 의약분업안이 도출되었으나 의료계의 반대로 합의에 이르지 못하였다. 제 3기에는 시민단체가 주도적인 역할을 수행하면서 의약분업안을 합의하였으나 의료계에서는 시민단체의 의약분업안을 반대하였다. 정부는 「의약분업실행위원회」를 구성하여 시민단체에 의해 도출된 의약분업안을 토대로 약사법을 개정하였다. 제 4기는 의료계의 반대에도 불구하고 약사법이 개정되고 의약품실거래가 상환제가 실시되자 의료계는 자신들의 요구를 관철시키기 위하여 집단행동을 하게 되었다. 의약분업정책 형성과정은 초기에는 정부에 의해 구성된 「의약분업추진협의회」와 「의약분업실행위원회」에 의해 정책공동체 유형을 띠었다. 그러나 '갈등관계'에 있는 이익집단과 정부관료, 시민단체의 대표들로 구성된 정책공동체는 불안정하고 인위적인 공동체로 정책결정에 실패하면서 사라졌다. 이후 의약분업정책 형성 과정에서 「보건의료발전특위」, 「의료발전특별위원회」 등이 만들어졌으나 형식적인 측면에 머무르고 있는 실정이다. 이러한 과정들을 살펴볼 때 의약분업정책 결정과정에서 「의약분업추진협의회」 와 「의약분업실행위원회」가 작동한 시기에는 참여자들의 공식적인 상호작용에 의해 정책결정이 이루어졌으나, 참여자들의 합의를 이루지는 못하였다. 이들 정책공동체에서는 다수결의 원리에 의해, 그리고 정부와 시민단체가 전략적으로 밀어붙이고, 여론을 동원함으로써 합의를 이끌어냈다. 따라서 합의된 의약분업안을 반대하는 정책참여자들의 행동에 의해 의약분업 정책네트워크는 이슈네트워크 유형으로 변화하였다. 정책공동체 형태에서 출발하여 이슈네트워크 유형으로 변화하면서 의약분업정책내용은 정책참여자들의 역학관계에 의하여 변화하였다. 시민단체가 정책결정의 주도권을 갖게 된 제 3기에 의약분업 정책내용은 병원을 포함한 모든 의료기관을 대상으로 하였다. 그리고 주사제를 포함시켰으며 광범위한 대체조제와 국민들의 편리를 위하여 어느 정도 소분판매를 허용하였다. 그러나 의료계가 주도권을 잡고 이슈네트워크 유형으로 변화하면서 의약분업 정책내용은 대체조제를 엄격하게 제한하고 있으며 임의조제를 근절하기 위하여 소분판매를 금지하고 있다. 그리고 정부는 약가실거래가 상환제를 실시한 후 4차례 의료수가를 인상하여 의·약·정 합의 이전까지 34.5%의 수가가 인상되었다. 이러한 정책내용은 정책공동체 유형을 유지하면서 시민단체가 주도권을 잡고 있던 제 3기에서는 약사회의 정책이익에 부합한 정책내용이 결정되었으나 이슈 네트워크로 변한 제 4기에는 의료계가 주도권을 갖게되었고 의약분업정책내용은 의료계의 요구사항이 상당부분 반영되게 되었다.
1963년부터 논쟁이 되어온 의약분업은 오랜 기간 동안 시행되지 못하고 표류하다가 1998년 김대중정부에 의해 본격적으로 추진되었다. 그리고 2년 반 동안의 격렬한 논쟁과 의료대란을 거치면서 2000년 7월부터 실시되었다. 의약분업정책은 과거의 보건의료정책이 정부와 이익집단 양자간에 의해 결정되었던 방식과는 달리 시민단체가 정책결정과정에 적극적으로 참여하였다. 시민단체의 참여로 의약분업정책은 공익성을 띄게 되었으며 국민과 여론의 관심을 높일 수 있었다. 그리고 이익집단의 활동을 견제하면서 의약분업정책을 추진할 수 있도록 정부에 힘을 실어주었다. 더욱이 보건의료 정책과정에 국민이 간접적으로나마 참여할 수 있는 참여민주주의 가능성이 열렸다는 측면에서 긍정적으로 평가할 수 있다. 그러나 의약분업정책은 ‘진료는 의사에게 조제는 약사에게’라는 간단한 구호와는 달리 우리나라의 전반적인 의료체계와 연관되어 있다. 그리고 의약분업정책을 결정하기 위해서는 우리나라 의료보험 제도와 제약산업, 의료전달체계 등 의료시스템에 대한 이해와 의료와 약에 대한 전문적인 지식이 필요하다. 그런데 이러한 전문성이 부족한 다수의 시민단체 대표가 참여하여, 정책참여자들간의 합의가 이루어지지 않은 상태에서 성급하게 밀어붙인 의약분업정책은, 의료계와의 갈등을 심화시키고 의료대란을 야기시켰다. 그리고 의약분업시행 이후 건강보험재정은 악화되었으며, 국민들의 불편감은 증가되고, 임의조제는 여전히 계속되며, 의약분업은 취약계층의 의료이용을 저하시키는 결과를 가져왔다. 본 연구는 의약분업정책에 대한 이러한 문제의식을 가지고 의약분업 정책형성 과정을 정책의 흐름과 변화에 따라 네 단계(제 1기 : 정책의 시동기, 제 2기 : 정책의 지연기, 제 3기 : 정책협력기, 제 4기 : 정책갈등기)로 구분하였다. 그리고 각 시기별로 의약분업정책의 결정과정을 정책네트워크모형에 의해 분석하였다. 정책네트워크을 통해 의약분업정책을 분석한 이유는 의약분업정책의 주요 참여자인 정부, 이익집단, 시민단체가 정책결정권을 비교적 동등하게 공유하였으며, 정책네트워크가 어떤 유형을 적었느냐에 따라 그리고 누가 정책결정에 주도적인 역할을 하였느냐에 따라 정책내용이 변화하였기 때문이다. 따라서 정책참여자와 이들의 상호작용에 의해 변화하는 정책네트워크유형이 정책내용에 어떻게 영향을 미쳤는가를 분석하였다. 분석결과 의약분업정책의 주요 참여자는 보건복지부, 의사협회, 약사회, 시민단체이며 형성단계에 따라 대통령, 정부여당과 야당, 국회의원, 언론 등이 참여하였다. 제 1기에서는 보건복지부가 의약분업추진을 위하여 구성한 「의약분업추진협의회」에 의해 정책이 결정되었으며 제 2기에서는 「의약분업추진협의회」의 의약분업안을 반대하며 의료계와 약계가 의약분업실시를 지연시키기 위한 정책활동을 하였다. 그리고 「국민회의」에 의해 의약분업안이 도출되었으나 의료계의 반대로 합의에 이르지 못하였다. 제 3기에는 시민단체가 주도적인 역할을 수행하면서 의약분업안을 합의하였으나 의료계에서는 시민단체의 의약분업안을 반대하였다. 정부는 「의약분업실행위원회」를 구성하여 시민단체에 의해 도출된 의약분업안을 토대로 약사법을 개정하였다. 제 4기는 의료계의 반대에도 불구하고 약사법이 개정되고 의약품실거래가 상환제가 실시되자 의료계는 자신들의 요구를 관철시키기 위하여 집단행동을 하게 되었다. 의약분업정책 형성과정은 초기에는 정부에 의해 구성된 「의약분업추진협의회」와 「의약분업실행위원회」에 의해 정책공동체 유형을 띠었다. 그러나 '갈등관계'에 있는 이익집단과 정부관료, 시민단체의 대표들로 구성된 정책공동체는 불안정하고 인위적인 공동체로 정책결정에 실패하면서 사라졌다. 이후 의약분업정책 형성 과정에서 「보건의료발전특위」, 「의료발전특별위원회」 등이 만들어졌으나 형식적인 측면에 머무르고 있는 실정이다. 이러한 과정들을 살펴볼 때 의약분업정책 결정과정에서 「의약분업추진협의회」 와 「의약분업실행위원회」가 작동한 시기에는 참여자들의 공식적인 상호작용에 의해 정책결정이 이루어졌으나, 참여자들의 합의를 이루지는 못하였다. 이들 정책공동체에서는 다수결의 원리에 의해, 그리고 정부와 시민단체가 전략적으로 밀어붙이고, 여론을 동원함으로써 합의를 이끌어냈다. 따라서 합의된 의약분업안을 반대하는 정책참여자들의 행동에 의해 의약분업 정책네트워크는 이슈네트워크 유형으로 변화하였다. 정책공동체 형태에서 출발하여 이슈네트워크 유형으로 변화하면서 의약분업정책내용은 정책참여자들의 역학관계에 의하여 변화하였다. 시민단체가 정책결정의 주도권을 갖게 된 제 3기에 의약분업 정책내용은 병원을 포함한 모든 의료기관을 대상으로 하였다. 그리고 주사제를 포함시켰으며 광범위한 대체조제와 국민들의 편리를 위하여 어느 정도 소분판매를 허용하였다. 그러나 의료계가 주도권을 잡고 이슈네트워크 유형으로 변화하면서 의약분업 정책내용은 대체조제를 엄격하게 제한하고 있으며 임의조제를 근절하기 위하여 소분판매를 금지하고 있다. 그리고 정부는 약가실거래가 상환제를 실시한 후 4차례 의료수가를 인상하여 의·약·정 합의 이전까지 34.5%의 수가가 인상되었다. 이러한 정책내용은 정책공동체 유형을 유지하면서 시민단체가 주도권을 잡고 있던 제 3기에서는 약사회의 정책이익에 부합한 정책내용이 결정되었으나 이슈 네트워크로 변한 제 4기에는 의료계가 주도권을 갖게되었고 의약분업정책내용은 의료계의 요구사항이 상당부분 반영되게 되었다.
From 1963 until July of 2000, there had been a 37 year old dispute over the lack of enforcement of the separation of dispensary from medical practice. This policy was finally enforced in July 2000 during the Kim, Dae-Jung administration. The first reason for this is that in Korea medicine was widely...
From 1963 until July of 2000, there had been a 37 year old dispute over the lack of enforcement of the separation of dispensary from medical practice. This policy was finally enforced in July 2000 during the Kim, Dae-Jung administration. The first reason for this is that in Korea medicine was widely distributed causing misuse and a tolerance to antibiotics that has been reported to be the highest in the world. Secondly, the enforcement of this policy for the separation became one of the promises made by the administration after the change in political power. Thirdly, the revision of Pharmaceutical Affairs Law in 1994 clearly stated that the enforcement of the separation of dispensary from medical practice should have begun in July of 1999. Finally, the enforcement of the separation of dispensary from medical practice was discussed by health and medical scholars during the debates on medical treatment reform. In the past, both the government and interested groups depended on the decisions on the policy for separation of dispensary from medical practice however, nongovernmental organizations (NGOs) were also participating in the decision making process. This research looks at the changes in policy due to the policy networks formed by the decision making process for the policy on the separation of dispensary from medical practice. This research studies the decisions on the policy for the separation of dispensary from medical practice during the period from March 1998 to November 2000. During this time, the formation of this policy can be divided into 4 stages. In order to analyze the policy network in each stage, certain terms were considered such as background, participants, policy process, and policy content. The research results of Stage I showed the Ministry of Health and Welfare began preparation for the enforcement of the separation of dispensary from medical practice beginning July 1999. T he Ministry of Health and Welfare formed a committee consisting of civil servants, representative doctors, representative pharmacists, NGOs, scholars and others to manage the plan for this separation. This committee for the promotion of this separation was made up of 20 members; 3 doctors, 3 pharmacists and 14 other members from the government, NGOs, scholars and members of the mass media which differed form the old style of just the government and affected parties making decisions. At the first meeting of this committee was proposed a 3 level bill on the separation of dispensary from medical practice. However, beginning July of 1999 special medicines excluding injections were enforced at clinics and pharmacies but not hospitals. Also, brand name prescription medicines and regular prescriptions could be used together. It also, became possible to change the compounding of medicine if found biologically equal. Finally, it was decided that 49.1% would be made up of general medicine and 50.9% would be made up of special medicine. Both doctors and pharmacists were dissatisfied with this bill. This was the beginning of the end for the cooperation in the policy network between the Korean Medical Association (KMA), the Korean Pharmacist Association (KPA) and NGOs. And a pattern of a policy community began to broken. In Stage II, doctors, pharmacists and NGOs all refused the bill. Doctors and pharmacists insisted on delaying the enforcement. The KMA and the KPA began using members of the National Assembly to lobby for a delay on the separation issue. The actions of the affected parties clouded efforts for enforcing the separation and exposed their irregularities. As societal issues about the irregularities of doctors came to form, an opportunity for NGOs to participate arose nation wide. In Stage I the Ministry of Health and Welfare took leadership in promoting the policy for separating dispensing from medical practice. In Stage II the enforcement became clouded and uncertain. The promotion of this policy came under the direction of the government's current ruling party, President Kim, Dae-Jung. Although the ruling government, KMA, KPA and the Ministry of Health and Welfare participated in the bill, a mutual agreement could not be reached. The KMA, KPA and NGOs promised to pass the bill within two months and delay the enforcement for one year. Due to the leadership of the ruling government party the separation of dispensary from medical practice including injections as special medicines was enforced to all medical facilities and pharmacies. Selling general medicine by individual units was no longer permitted except for PTP and Foil. The government met the demands of the KPA on the bill and afterwards a draft was presented to the NGOs. In Stage II, policy participants issued statements, submitted written petitions to the National Assembly and sent letters in order to exert influence on the decisions. The participants in this policy, KMA and KPA insisted on delaying the separation and NGOs and government insisted on its enforcement. However, when the government's leadership prepared the bill, it was supported by the KPA but the KMA opposed it. Stage II provided more freedom for policy participants of the policy network. This was also a stage where cooperation and conflict changed among participants on the decisions of the bill. Finally, there was a change from a pattern of a policy community to a pattern of a issue network. In Stage III, the KMA, KPA and NGOs promised cooperation for 2 months on the bill. At this time, the NGOs took leadership and assigned roles. The NGOs organized and held a debate forum at the "NGOs Policy Committee" in order to prepare the bill. The KMA, KPA, and politicians participated in the 5 round debates and came up with a bill. The KMA refused the new bill that "NGOs Policy Committee" prepared. But aware of the public criticism about the deadline for a promised agreement, on May 10th, an agreement was signed by KMA. In this agreement health centers included all health agencies, injections included as special medicine, and brand name medicines could be used together with regular medicines. In classification, the ratio for special medicines to general medicines became 56.3% to 39.1% respectively. The government accepted the bill and formed new commute. The committee for the enforcement of the separation formed and composed of 26 members; 3 doctors, 3 pharmacists and 20 other members. This bill was finally confirmed despite the continual resistance from the doctors. Doctors refused the bill and began a signature collecting campaign against the separation. The doctors proposed the problem with the bill was with pharmacist's permission of optional compounding of medicines and substitute compounding of medicine. In Stage III the policy was the center of a debate forum by the NGO Policy Committee and after that the committee for the enforcement of the separation was formed. The committee for the enforcement of the separation was similar to the committee for the promotion of the separation formed in Stage I. The government created the enforcement committee as a policy community. The resistant doctors made this policy community unstable in the policy network by collection signatures and using the media for advertisement campaigns. In Stage IV the government introduced a system for medical business transactions that would eliminate margins. The introduction of this system stirred up resistance amongst doctors. Doctors demanded the government for improvement and reform in the medical treatment by taking action in large scale demonstrations and strikes which caused great disturbances. NGOs and the press called doctors selfish for influencing there opposition to medical treatment reform. During this period the Ministry of Health and Welfare, the president, the government ruling party, the opposition party, the National Assembly, and prosecutors all participated in the policy. For doctors; hospital owners, specialists, students, and medical professors participated. For the KPA; students and pharmaceutical professors participated. All acted by negotiating, interviewing, meeting, advertising, conferencing, and striking. At this time they all participated to continue this policy but the mutual agreement about this policy was broken. In this process where an agreement was made on the bill, the substitute compounding of medicine was prohibited as well as the individual sales of general medicine. Also a plan was drawn up for pharmacists to take custody of pharmaceutical record books for 5 years. Each time the separation policy came under new leadership, the contents changed also. When the form of the policy community started the issue network changed too. As the issue network changed, the following problems arose: First, the government had the will to enforce the separation, however, it was not fully prepared. Second, the NGOs' goal was for enforcement of the policy, but instead of criticizing the government for its lack of sufficient preparation, they blamed the doctors. Third, A majority decision without doctors' agreement brought on the doctor strikes. Fourth, even though the NGOs did not have sufficient technical information about the separation policy, they played a role in leadership for the policy decision making process in Stages I, II and III. These were the problems of the policy decisions and content for the separation of dispensing from medical practice.
From 1963 until July of 2000, there had been a 37 year old dispute over the lack of enforcement of the separation of dispensary from medical practice. This policy was finally enforced in July 2000 during the Kim, Dae-Jung administration. The first reason for this is that in Korea medicine was widely distributed causing misuse and a tolerance to antibiotics that has been reported to be the highest in the world. Secondly, the enforcement of this policy for the separation became one of the promises made by the administration after the change in political power. Thirdly, the revision of Pharmaceutical Affairs Law in 1994 clearly stated that the enforcement of the separation of dispensary from medical practice should have begun in July of 1999. Finally, the enforcement of the separation of dispensary from medical practice was discussed by health and medical scholars during the debates on medical treatment reform. In the past, both the government and interested groups depended on the decisions on the policy for separation of dispensary from medical practice however, nongovernmental organizations (NGOs) were also participating in the decision making process. This research looks at the changes in policy due to the policy networks formed by the decision making process for the policy on the separation of dispensary from medical practice. This research studies the decisions on the policy for the separation of dispensary from medical practice during the period from March 1998 to November 2000. During this time, the formation of this policy can be divided into 4 stages. In order to analyze the policy network in each stage, certain terms were considered such as background, participants, policy process, and policy content. The research results of Stage I showed the Ministry of Health and Welfare began preparation for the enforcement of the separation of dispensary from medical practice beginning July 1999. T he Ministry of Health and Welfare formed a committee consisting of civil servants, representative doctors, representative pharmacists, NGOs, scholars and others to manage the plan for this separation. This committee for the promotion of this separation was made up of 20 members; 3 doctors, 3 pharmacists and 14 other members from the government, NGOs, scholars and members of the mass media which differed form the old style of just the government and affected parties making decisions. At the first meeting of this committee was proposed a 3 level bill on the separation of dispensary from medical practice. However, beginning July of 1999 special medicines excluding injections were enforced at clinics and pharmacies but not hospitals. Also, brand name prescription medicines and regular prescriptions could be used together. It also, became possible to change the compounding of medicine if found biologically equal. Finally, it was decided that 49.1% would be made up of general medicine and 50.9% would be made up of special medicine. Both doctors and pharmacists were dissatisfied with this bill. This was the beginning of the end for the cooperation in the policy network between the Korean Medical Association (KMA), the Korean Pharmacist Association (KPA) and NGOs. And a pattern of a policy community began to broken. In Stage II, doctors, pharmacists and NGOs all refused the bill. Doctors and pharmacists insisted on delaying the enforcement. The KMA and the KPA began using members of the National Assembly to lobby for a delay on the separation issue. The actions of the affected parties clouded efforts for enforcing the separation and exposed their irregularities. As societal issues about the irregularities of doctors came to form, an opportunity for NGOs to participate arose nation wide. In Stage I the Ministry of Health and Welfare took leadership in promoting the policy for separating dispensing from medical practice. In Stage II the enforcement became clouded and uncertain. The promotion of this policy came under the direction of the government's current ruling party, President Kim, Dae-Jung. Although the ruling government, KMA, KPA and the Ministry of Health and Welfare participated in the bill, a mutual agreement could not be reached. The KMA, KPA and NGOs promised to pass the bill within two months and delay the enforcement for one year. Due to the leadership of the ruling government party the separation of dispensary from medical practice including injections as special medicines was enforced to all medical facilities and pharmacies. Selling general medicine by individual units was no longer permitted except for PTP and Foil. The government met the demands of the KPA on the bill and afterwards a draft was presented to the NGOs. In Stage II, policy participants issued statements, submitted written petitions to the National Assembly and sent letters in order to exert influence on the decisions. The participants in this policy, KMA and KPA insisted on delaying the separation and NGOs and government insisted on its enforcement. However, when the government's leadership prepared the bill, it was supported by the KPA but the KMA opposed it. Stage II provided more freedom for policy participants of the policy network. This was also a stage where cooperation and conflict changed among participants on the decisions of the bill. Finally, there was a change from a pattern of a policy community to a pattern of a issue network. In Stage III, the KMA, KPA and NGOs promised cooperation for 2 months on the bill. At this time, the NGOs took leadership and assigned roles. The NGOs organized and held a debate forum at the "NGOs Policy Committee" in order to prepare the bill. The KMA, KPA, and politicians participated in the 5 round debates and came up with a bill. The KMA refused the new bill that "NGOs Policy Committee" prepared. But aware of the public criticism about the deadline for a promised agreement, on May 10th, an agreement was signed by KMA. In this agreement health centers included all health agencies, injections included as special medicine, and brand name medicines could be used together with regular medicines. In classification, the ratio for special medicines to general medicines became 56.3% to 39.1% respectively. The government accepted the bill and formed new commute. The committee for the enforcement of the separation formed and composed of 26 members; 3 doctors, 3 pharmacists and 20 other members. This bill was finally confirmed despite the continual resistance from the doctors. Doctors refused the bill and began a signature collecting campaign against the separation. The doctors proposed the problem with the bill was with pharmacist's permission of optional compounding of medicines and substitute compounding of medicine. In Stage III the policy was the center of a debate forum by the NGO Policy Committee and after that the committee for the enforcement of the separation was formed. The committee for the enforcement of the separation was similar to the committee for the promotion of the separation formed in Stage I. The government created the enforcement committee as a policy community. The resistant doctors made this policy community unstable in the policy network by collection signatures and using the media for advertisement campaigns. In Stage IV the government introduced a system for medical business transactions that would eliminate margins. The introduction of this system stirred up resistance amongst doctors. Doctors demanded the government for improvement and reform in the medical treatment by taking action in large scale demonstrations and strikes which caused great disturbances. NGOs and the press called doctors selfish for influencing there opposition to medical treatment reform. During this period the Ministry of Health and Welfare, the president, the government ruling party, the opposition party, the National Assembly, and prosecutors all participated in the policy. For doctors; hospital owners, specialists, students, and medical professors participated. For the KPA; students and pharmaceutical professors participated. All acted by negotiating, interviewing, meeting, advertising, conferencing, and striking. At this time they all participated to continue this policy but the mutual agreement about this policy was broken. In this process where an agreement was made on the bill, the substitute compounding of medicine was prohibited as well as the individual sales of general medicine. Also a plan was drawn up for pharmacists to take custody of pharmaceutical record books for 5 years. Each time the separation policy came under new leadership, the contents changed also. When the form of the policy community started the issue network changed too. As the issue network changed, the following problems arose: First, the government had the will to enforce the separation, however, it was not fully prepared. Second, the NGOs' goal was for enforcement of the policy, but instead of criticizing the government for its lack of sufficient preparation, they blamed the doctors. Third, A majority decision without doctors' agreement brought on the doctor strikes. Fourth, even though the NGOs did not have sufficient technical information about the separation policy, they played a role in leadership for the policy decision making process in Stages I, II and III. These were the problems of the policy decisions and content for the separation of dispensing from medical practice.
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