地域を守る医療ガバナンスの課題

－山形県小国町における公立病院改革への対応を事例に－

抄録

In recent years, public hospitals in Japan's rural areas, which are the main providers of medical care in rural areas, have been experiencing worsening financial conditions. In response, in 2007, the Ministry of Internal Affairs and Communications issued public hospital reform guidelines to local municipalities, requesting that they improve public hospital management as quickly as possible. Because the worsening fi nancial position of public hospitals is linked to their special organizational structure of strong ties with local governments, the guidelines urged making hospitals managerially independent from municipalities. However, in rural areas that would be especially strongly affected by the guidelines, the issue of medical care is an administrative issue of high public interest, and public hospitals and municipalities are linked inseparably. Consequently, whether the independence of public hospitals from municipalities as proposed by the guidelines is suitable for rural areas persists as an important research subject.
This study, which was conducted to clarify management improvement measures for public hospitals in rural areas and benefi cial governance structures necessary to enable such measures, examined Oguni-Town in Yamagata Prefecture, which improved management of public hospitals without making them independent from municipalities. Measures adopted and implemented by the Oguni public hospital during 2008.2011, including the implementation of a change in the classification of hospital beds, promotion of medical examinations, and introduction of generic drugs, raised medical practice income and contributed to the improvement of management. These measures were developed through cooperation and the exchange of ideas among medical personnel of various specialties and local government officials. Such collaboration is a method that has been emphasized by Oguni-Town throughout its town planning activities. Through the use of common methods, administrative support for public hospital reform was obtained readily. Because the protection of medical care in rural areas is an important part of community building, it can be argued that maintaining a close relation between medical care providers and the community is important.