台灣預防接種體制之變遷-以水痘、肺炎鏈球菌疫苗觀之

The Change of Taiwan Immunization System–Varicella and Pneumococcal Conjugate Vaccine Cases

黃柔翡(Jou-Fei Huang)

指導教授 ： 王宏文

國立臺灣大學/社會科學院/政治學研究所/碩士(2014年)

https://doi.org/10.6342/NTU.2014.03102

摘要

我國於戰後建立「中央指導、地方執行」的預防接種體制，有效回應傳染病肆虐的問題，更因成功防治B型肝炎的經驗受到國際肯定，但1990年代後期出現了地方政府相繼推動各自的疫苗政策，而中央政府卻落後之，甚至無所作為的情形。究竟是何種因素改變原有的體制建置，讓地方政府擁有預防接種政策的決策權？另外，一向專業性較中央低的地方政府又如何論證其公衛治理正當性呢？ 本研究透過政策變遷理論來分析地方政府為何願意、如何參與並形塑疫苗政策，並透過水痘疫苗和肺炎鏈球菌疫苗兩個案來描繪中央與地方政府之間的競合關係。
本文發現，民主化之後，預防接種體制的變遷可用「中央放權、收權、規範式放權」來形容之。1990年代末期開始，地方政府和縣市議員以爭取小兒福利、保障弱勢群體權益、減少家庭支出為名，推動免費疫苗接種政策，將預防接種政策的政策形象從重視「群體免疫」的疾病防治轉變為關注「公平正義」的福利導向，而中央疾管局囿於預算阻礙而暫失決策能力。但因治理規模和專業性的問題，中央著手匡正地方政府紛雜的疫苗政策並重新取得決策權，藉由於2009年修訂傳染病防治法第27條，將預防接種體制的專業決策制度化，讓中央得以掌握關乎疫苗選擇與評估的工作，而縣市政府則爭取到福利政策的施政空間。本文藉由新聞內容分析法發現預防接種政策的形象從專業轉向專業與福利並陳，而這也是地方政府願意且何以介入疫苗決策的方式，不過政策形象與轄區仍處在變動的階段，蓋現行各地方政府競相推動的子宮頸癌疫苗政策可能會加劇福利性論述，進而根本性的改變疫苗原本於傳染病防治中的意涵。

關鍵字

政策變遷 ； 政策形象 ； 政策轄區 ； 預防接種

並列摘要

The success of Taiwan’s infectious disease control and eradication, as well as its hepatitis B prevention program, have been highly praised around the world. This success has been ascribed to the effective immunization structure – from the central government to local public health bureaus – that relies on good governance and cooperation to fulfill the goal of disease control. However, in the late 1990s, local governments started to promote their own vaccine policies, while the central government lagged behind and made no progress. What factors changed the well-functioning “central decision and local execution” hierarchy system? How did the local governments, which are considered as holding a lower level of professionalism, gain the justification to decide immunization policies? This research explains how local governments were willing and able to step in to handle immunization policy, and through two case studies –Varicella and Pneumococcal Conjugate Vaccine – explains the Co-optive Relationship between central and local government.

The research shows that the change in the immunization system after democratization could be described as “central delegated, central regained the power, and regulated delegation”. Since the late 1990s, the local governments and legislators actively promoted their own free vaccine policies in the name of “fighting for the welfare of children”, “protecting the rights of vulnerable groups”, and “reducing families’ expenses”. While the action of the central government was restrained by the budget, local governments reshaped the images of the vaccines, from being associated with disease prevention focusing on herd immunity and shifting to welfare orientation focusing on fairness and justice. However, the central government indicated that the lesser governance and lower professionalism of local governments caused the mismanagement of resources and waste. Through the revision of Law on the Control of Communicable Diseases in 2009, the role of a professional decision system was assured, allowing the central government to regain the power of vaccine selection and policy elevation, while the policy direction of local governments has been regulated, and have the margin of providing welfare policy. From interviews and content analysis, I found that the policy image of the immunization policy has changed from professionalism to both welfare and professionalism, which is the key factor to how local governments were willing and able to step into the competition of policy venue. However, the HPV policies that are promoted by various local governments could sway the stability of image and venue, and could possibly change the role and meaning of vaccination in infectious disease control.

並列關鍵字

policy change ； policy image ； policy venue ； immunization

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