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ADB's strategic objectives and priorities. The Nepal country partnership strategy (CPS), 2020–2024 of the Asian Development Bank (ADB) has three objectives: (i) improved infrastructure for private sector-led growth, (ii) improved access to devolved services, and (iii) environmental sustainability and resilience. ADB will support renewable energy, road and air transport, logistics, and trade facilitation to strengthen domestic, regional, and international connectivity; reduce the costs of production and trade for businesses; and attract private investment. Improved access to devolved services will entail assistance for (i) the development of cities and urban municipalities, (ii) quality education and employment-oriented skills development, and (iii) increased agriculture productivity and commercialization to augment rural incomes. These will be targeted to benefit women and disadvantaged social groups. ADB will support integrated water resource management, as well as the formulation and implementation of policies and plans, for stronger resilience and environmental sustainability. ADB will assist with policy reforms for devolved service delivery, including subnational public financial management (PFM); and sector reforms in agriculture, air transport, and water supply. Knowledge solutions and development of institutional capacity, especially at subnational levels, will be emphasized.

This trans-disciplinary scholarly annual journal aims to provide a diverse array of research and working papers, policy briefs, and argumentative essays on issues pertaining to sustainable development. From sustainable livelihoods to social sector development, from inclusive economic growth to institutional governance, from energy economics to climate change, from food in/security, water and human security to education, from sustainable industrial growth to resilient development, from religious tolerance to peace and gender equity, there will be something insightful for professionals, students, and readers from varied backgrounds.

Dottorato di ricerca in Scienze delle produzioni vegetali e animali ; Despite some deniers still persist, the evidences of climate change (CC) are currently growing before our eyes, and global warming is one of the major threats to public global health. The world is way behind on its commitment to reduce greenhouse gas (GHG) emissions, and in the next decades, nations must make an unprecedented effort to cut their levels of GHG to avoid climate chaos. By providing food to about 7.7 billion of people, agriculture contributes to a significant share (11-12%) of the global GHG emissions, especially because of methane (CH4) and nitrous oxide (N2O) emissions sources. However, if it is true that agriculture is a part of the CC problem, it is equally true that agriculture could be a part of the solution. Carbon sequestration in the agriculture sector is the capacity of agricultural lands and forest to remove CO2 from the atmosphere. Specifically, CO2 is absorbed by trees, plants and crops through photosynthesis, and stored as cellulose, hemicellulose and lignin in tree trunks, branches, foliage, roots and soils. As a result, soils are the largest terrestrial carbon sink in the planet. Therefore, if on one hand a release of just 0.1% of the soil organic carbon (SOC) currently stocked in European soils would be equal to the annual emissions from 100 million cars, on the other hand, a small increase of its content would significantly reduce the CO2 concentration in atmosphere. The dynamics (i.e., increase and decrease) of SOC are highly influenced by agricultural practices, climate and soil. In this context, by employing farming practices that involve minimal disturbance of the soil and the use of organic fertilizers, farmers may be able to increase the amount of SOC in their fields, and thus contribute to both soil fertility maintenance, and global GHG mitigation. However, although SOC sequestration could be a great ally in the fight against CC, the sustainability of the agricultural sector cannot be achieved by focusing solely on the upstream processes of the system, and GHG mitigation opportunities must be identified also at later stages of the supply chain. In this regard, by allowing the evaluation of the overall environmental impacts generated along a product/service life cycle (i.e., from raw material acquisition, through production and utilization phases, to waste management), the Life Cycle Assessment (LCA) is a useful tool that could help in defining effective mitigation strategies. Nowadays, the need for verified and credible information on GHG emissions is increasing, with pressure coming from a wide range of interest groups (e.g., governmental and nongovernmental organizations) aimed on reducing greenwashing. In this respect, the environmental labels based on LCA studies are valuable tools to establish credible green marketing claims. This thesis is composed of three studies which have used the LCA approach to investigate the GHG emissions arising from different systems involving anthropogenic activities. In the first study, the LCA approach was used to quantify the overall GHG emissions (from cradle-to-grave) generated by a local organic beef supply chain. The study identifiesthe main GHG hotspots, and suggests some mitigation practices that could be applicable along the short supply chain. In the second study, the LCA approach allowed the evaluation of the GHG emissions (from cradle-to-farm-gate) arising from a farm that rears native beef cattle within a Mediterranean natural reserve of Italy. Specifically, in this study different agronomic practices, grazing management and climate scenarios were evaluated for their contribution on the soil GHG emissions and sinks, and thus the overall farm carbon footprint. Finally, the third and last study aimed at developing a standard (LCA-based) guideline to be followed when assessing the GHG emissions (from cradle-to-grave) generated by all the common activities taking place within a National park. Particularly, the feasibility and applicability of the guideline proposed, was tested using a Mediterranean natural reserve of Italy as case study. Although GHG hotspots and mitigation strategies were discussed within the paper, the final aim of the work was to propose a widely accepted LCA-based guideline to be followed in order to obtain an environmental declaration for natural parks. The results of this PhD thesis provide interesting insights about the GHG emissions arising from typical beef systems of the Mediterranean area, and about some possible related mitigation strategies. Although the livestock and soil emissions resulted as the main GHG hotspots of the beef supply chain, home consumption and retail phases have also shown potential room for improvement. The adoption of conservation tillage practices and the use of organic fertilizers were shown to be effective in mitigating the GHG emissions arising from the beef farm system. While, by providing a granular picture of the Mediterranean natural reserve' GHG emission sources and hotspots, the proposed LCA-based guideline shown to feasible and suitable in achieving the planned objectives. ; Nonostante l'insistenza di qualche instancabile negazionista, i cambiamenti climatici (CC) stanno avendo, e ancor di più avranno in futuro, rilevanti impatti sugli ecosistemi e sulle attività umane. Secondo l'ultimo report (2019) del Gruppo Intergovernativo sul Cambiamento Climatico (IPCC), il riscaldamento globale provocherà un aumento di siccità e piogge estreme in tutto il mondo, pregiudicando la produzione agricola e la sicurezza delle forniture alimentari. A pagarne le conseguenze saranno soprattutto le popolazioni più povere di Africa e Asia, con guerre e migrazioni. Attualmente, il mondo è indietro rispetto agli impegni presi per ridurre le emissioni di gas serra (GHG) e le nazioni devono compiere uno sforzo senza precedenti per ridurre i loro livelli di GHG nei prossimi decenni, solo così saremo in grado di evitare il caos climatico. Fornendo cibo a circa 7,7 miliardi di persone nel mondo, l'agricoltura contribuisce ad una quota significativa (11-12%) delle emissioni globali di GHG, soprattutto a causa delle importanti fonti emissive di metano (CH4) e protossido di azoto (N2O). Tuttavia, se è vero che l'agricoltura contribuisce al cambiamento climatico, è altrettanto vero che la stessa agricoltura può diventare parte della soluzione. Con il termine sequestro di carbonio, si fa riferimento alla capacità delle terre e delle foreste di rimuovere la CO2 dall'atmosfera. Attraverso il processo della fotosintesi infatti, la CO2 assorbita da alberi, piante e colture, viene immagazzinata nella biomassa di tronchi, rami, radici e suolo. Di conseguenza, i suoli rappresentano il più grande magazzino di carbonio del pianeta. Pertanto, se da una parte il rilascio dello appena 0,1% del carbonio contenuto attualmente nei suoli Europei può essere paragonabile alle emissioni annuali generate da 100 milioni di automobili, dall'altra, un altrettanto piccolo incremento di questo contenuto può avere effetti significativi sulla riduzione di CO2 nell'atmosfera. Le dinamiche (ovvero incremento e decremento) del carbonio organico contenuto nel suolo (SOC) sono fortemente influenzate dalle pratiche agricole, dal clima e dalla tipologia di terreno. In questo contesto, tramite l'impiego di pratiche agricole che comportano un disturbo minimo del suolo e l'utilizzo di fertilizzanti organici, gli agricoltori possono contribuire sia al mantenimento della fertilità del suolo, sia alla mitigazione globale dei GHG. Tuttavia, nonostante il sequestro di SOC rappresenti un grande alleato nella lotta al CC, la sostenibilità del settore agricolo non può essere raggiunta concentrandosi esclusivamente sui processi a monte del sistema, ma le opportunità di mitigazione dei GHG devono essere valutate e intraprese anche nelle fasi successive della catena di approvvigionamento. A questo scopo, consentendo la valutazione degli impatti ambientali generati lungo il ciclo di vita di un prodotto o di un servizio (ovvero, dall'acquisizione delle materie prime, passando per le fasi di produzione e utilizzo, arrivando fino alla gestione del rifiuto generato), la valutazione del ciclo di vita (LCA) è una tipologia di analisi che può essere di aiuto nel definire efficaci interventi e strategie di mitigazione. Al giorno d'oggi, la necessità di informazioni verificate e credibili sulle emissioni di GHG è in costante aumento, con pressioni provenienti da una vasta gamma di gruppi di interesse (es., organizzazioni governative e non governative) determinati a ridurre le strategie di comunicazione ingannevoli (greenwashing) che le imprese spesso utilizzano per creare una falsa immagine positiva sotto il profilo ambientale. A questo proposito, le etichette ambientali basate su studi LCA diventano strumenti preziosi per tutte le aziende che vogliono intraprendere operazioni credibili e verificate di marketing ambientale. Questa tesi di dottorato si compone di tre studi che, tramite l'utilizzo dell'approccio LCA, hanno investigato le emissioni di GHG provenienti da diversi sistemi antropogenici. Nel primo studio la metodologia LCA è stata coinvolta nella quantificazione delle emissioni GHG (dalla culla alla tomba) generate lungo una catena di approvvigionamento locale di carne bovina biologica, con lo scopo di: identificarne i principali punti emissivi (hotspots) e suggerire interventi di mitigazione applicabili lungo tutta la filiera. Nel secondo studio, l'analisi LCA è stata applicata alla quantificazione delle emissioni GHG (dalla culla al cancello della fattoria) derivanti da un'azienda agricola che alleva bovini di razza Maremmana all'interno di una riserva naturale Mediterranea del centro Italia. Nello specifico, in questo studio sono state analizzate le dinamiche con cui l'adozione di diverse pratiche agronomiche, gestione del pascolo e scenari climatici futuri, possono influenzare le emissioni di GHG e gli stoccaggi di SOC, e di conseguenza l'impronta emissiva (impronta di carbonio) totale prodotta dall'azienda. Infine, il terzo ed ultimo studio è stato incentrato allo sviluppo di una linea guida standard (basata sull'approccio LCA) da adottare al fine di valutare le emissioni di GHG (dalla culla alla tomba) generate da tutte le attività che prendono luogo generalmente all'interno di un parco/riserva nazionale. In particolare, l'applicabilità della linea guida proposta è stata testata in un caso studio che ha interessato la riserva naturale Mediterranea menzionata precedentemente. Sebbene nel documento siano stati discussi anche hotspots e possibili strategie di mitigazione, lo scopo finale del lavoro è stato quello di sviluppare una linea guida in grado di fornire un approccio LCA standardizzato da poter essere impiegato dai parchi naturali per intraprendere operazioni di marketing ambientale. I risultati di questa tesi di dottorato forniscono interessanti spunti sulle emissioni di GHG derivanti dai tipici sistemi di allevamento di carne bovina dell'area del Mediterraneo, e su alcune delle possibili correlate strategie di mitigazione. Sebbene le emissioni di GHG generate dagli animali e dal suolo siano risultate le principali fonti di emissione lungo la catena di approvvigionamento della carne, sia i consumi domestici che la vendita al dettaglio hanno mostrato potenziali margini di miglioramento. L'adozione di pratiche agronomiche meno invasive e l'uso di fertilizzanti organici hanno dimostrato di essere efficaci nel mitigare le emissioni di GHG derivanti dal comparto agricolo. Infine, avendo fornito un quadro dettagliato dei principali hotspots della riserva naturale Mediterranea, la linea guida proposta in questa tesi ha dimostrato di essere adatta all'utilizzo dei suoi risultati per operazioni di marketing ambientale da parte dei parchi nazionali.

Publisher's version (útgefin grein) ; Background Achieving universal health coverage (UHC) involves all people receiving the health services they need, of high quality, without experiencing financial hardship. Making progress towards UHC is a policy priority for both countries and global institutions, as highlighted by the agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13). Measuring effective coverage at the health-system level is important for understanding whether health services are aligned with countries' health profiles and are of sufficient quality to produce health gains for populations of all ages. Methods Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we assessed UHC effective coverage for 204 countries and territories from 1990 to 2019. Drawing from a measurement framework developed through WHO's GPW13 consultation, we mapped 23 effective coverage indicators to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (>= 65 years). Effective coverage indicators were based on intervention coverage or outcome-based measures such as mortality-to-incidence ratios to approximate access to quality care; outcome-based measures were transformed to values on a scale of 0-100 based on the 2.5th and 97.5th percentile of location-year values. We constructed the UHC effective coverage index by weighting each effective coverage indicator relative to its associated potential health gains, as measured by disability-adjusted life-years for each location-year and population-age group. For three tests of validity (content, known-groups, and convergent), UHC effective coverage index performance was generally better than that of other UHC service coverage indices from WHO (ie, the current metric for SDG indicator 3.8.1 on UHC service coverage), the World Bank, and GBD 2017. We quantified frontiers of UHC effective coverage performance on the basis of pooled health spending per capita, representing UHC effective coverage index levels achieved in 2019 relative to country-level government health spending, prepaid private expenditures, and development assistance for health. To assess current trajectories towards the GPW13 UHC billion target-1 billion more people benefiting from UHC by 2023-we estimated additional population equivalents with UHC effective coverage from 2018 to 2023. Findings Globally, performance on the UHC effective coverage index improved from 45.8 (95% uncertainty interval 44.2-47.5) in 1990 to 60.3 (58.7-61.9) in 2019, yet country-level UHC effective coverage in 2019 still spanned from 95 or higher in Japan and Iceland to lower than 25 in Somalia and the Central African Republic. Since 2010, sub-Saharan Africa showed accelerated gains on the UHC effective coverage index (at an average increase of 2.6% [1.9-3.3] per year up to 2019); by contrast, most other GBD super-regions had slowed rates of progress in 2010-2019 relative to 1990-2010. Many countries showed lagging performance on effective coverage indicators for non-communicable diseases relative to those for communicable diseases and maternal and child health, despite non-communicable diseases accounting for a greater proportion of potential health gains in 2019, suggesting that many health systems are not keeping pace with the rising non-communicable disease burden and associated population health needs. In 2019, the UHC effective coverage index was associated with pooled health spending per capita (r=0.79), although countries across the development spectrum had much lower UHC effective coverage than is potentially achievable relative to their health spending. Under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach $1398 pooled health spending per capita (US$ adjusted for purchasing power parity) in order to achieve 80 on the UHC effective coverage index. From 2018 to 2023, an estimated 388.9 million (358.6-421.3) more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Current projections point to an estimated 3.1 billion (3.0-3.2) population equivalents still lacking UHC effective coverage in 2023, with nearly a third (968.1 million [903.5-1040.3]) residing in south Asia. Interpretation The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people-the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close-or how far-all populations are in benefiting from UHC. ; Lucas Guimaraes Abreu acknowledges support from Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior -Brasil (Capes) -Finance Code 001, Conselho Nacional de Desenvolvimento Cientifico e Tecnologico (CNPq) and Fundacao de Amparo a Pesquisa do Estado de Minas Gerais (FAPEMIG). Olatunji O Adetokunboh acknowledges South African Department of Science & Innovation, and National Research Foundation. Anurag Agrawal acknowledges support from the Wellcome Trust DBT India Alliance Senior Fellowship IA/CPHS/14/1/501489. Rufus Olusola Akinyemi acknowledges Grant U01HG010273 from the National Institutes of Health (NIH) as part of the H3Africa Consortium. Rufus Olusola Akinyemi is further supported by the FLAIR fellowship funded by the UK Royal Society and the African Academy of Sciences. Syed Mohamed Aljunid acknowledges the Department of Health Policy and Management, Faculty of Public Health, Kuwait University and International Centre for Casemix and Clinical Coding, Faculty of Medicine, National University of Malaysia for the approval and support to participate in this research project. Marcel Ausloos, Claudiu Herteliu, and Adrian Pana acknowledge partial support by a grant of the Romanian National Authority for Scientific Research and Innovation, CNDSUEFISCDI, project number PN-III-P4-ID-PCCF-2016-0084. Till Winfried Barnighausen acknowledges support from the Alexander von Humboldt Foundation through the Alexander von Humboldt Professor award, funded by the German Federal Ministry of Education and Research. Juan J Carrero was supported by the Swedish Research Council (2019-01059). Felix Carvalho acknowledges UID/MULTI/04378/2019 and UID/QUI/50006/2019 support with funding from FCT/MCTES through national funds. Vera Marisa Costa acknowledges support from grant (SFRH/BHD/110001/2015), received by Portuguese national funds through Fundacao para a Ciencia e a Tecnologia (FCT), IP, under the Norma TransitA3ria DL57/2016/CP1334/CT0006. Jan-Walter De Neve acknowledges support from the Alexander von Humboldt Foundation. Kebede Deribe acknowledges support by Wellcome Trust grant number 201900/Z/16/Z as part of his International Intermediate Fellowship. Claudiu Herteliu acknowledges partial support by a grant co-funded by European Fund for Regional Development through Operational Program for Competitiveness, Project ID P_40_382. Praveen Hoogar acknowledges the Centre for Bio Cultural Studies (CBiCS), Manipal Academy of Higher Education(MAHE), Manipal and Centre for Holistic Development and Research (CHDR), Kalghatgi. Bing-Fang Hwang acknowledges support from China Medical University (CMU108-MF-95), Taichung, Taiwan. Mihajlo Jakovljevic acknowledges the Serbian part of this GBD contribution was co-funded through the Grant OI175014 of the Ministry of Education Science and Technological Development of the Republic of Serbia. Aruna M Kamath acknowledges funding from the National Institutes of Health T32 grant (T32GM086270). Srinivasa Vittal Katikireddi acknowledges funding from the Medical Research Council (MC_UU_12017/13 & MC_UU_12017/15), Scottish Government Chief Scientist Office (SPHSU13 & SPHSU15) and an NRS Senior Clinical Fellowship (SCAF/15/02). Yun Jin Kim acknowledges support from the Research Management Centre, Xiamen University Malaysia (XMUMRF/2018-C2/ITCM/0001). Kewal Krishan acknowledges support from the DST PURSE grant and UGC Center of Advanced Study (CAS II) awarded to the Department of Anthropology, Panjab University, Chandigarh, India. Manasi Kumar acknowledges support from K43 TW010716 Fogarty International Center/NIMH. Ben Lacey acknowledges support from the NIHR Oxford Biomedical Research Centre and the BHF Centre of Research Excellence, Oxford. Ivan Landires is a member of the Sistema Nacional de InvestigaciA3n (SNI), which is supported by the Secretaria Nacional de Ciencia Tecnologia e Innovacion (SENACYT), Panama. Jeffrey V Lazarus acknowledges support by a Spanish Ministry of Science, Innovation and Universities Miguel Servet grant (Instituto de Salud Carlos III/ESF, European Union [CP18/00074]). Peter T N Memiah acknowledges CODESRIA; HISTP. Subas Neupane acknowledges partial support from the Competitive State Research Financing of the Expert Responsibility area of Tampere University Hospital. Shuhei Nomura acknowledges support from the Ministry of Education, Culture, Sports, Science, and Technology of Japan (18K10082). Alberto Ortiz acknowledges support by ISCIII PI19/00815, DTS18/00032, ISCIII-RETIC REDinREN RD016/0009 Fondos FEDER, FRIAT, Comunidad de Madrid B2017/BMD-3686 CIFRA2-CM. These funding sources had no role in the writing of the manuscript or the decision to submit it for publication. George C Patton acknowledges support from a National Health & Medical Research Council Fellowship. Marina Pinheiro acknowledges support from FCT for funding through program DL 57/2016 -Norma transitA3ria. Alberto Raggi, David Sattin, and Silvia Schiavolin acknowledge support by a grant from the Italian Ministry of Health (Ricerca Corrente, Fondazione Istituto Neurologico C Besta, Linea 4 -Outcome Research: dagli Indicatori alle Raccomandazioni Cliniche). Daniel Cury Ribeiro acknowledges support from the Sir Charles Hercus Health Research Fellowship -Health Research Council of New Zealand (18/111). Perminder S Sachdev acknowledges funding from the NHMRC Australia. Abdallah M Samy acknowledges support from a fellowship from the Egyptian Fulbright Mission Program. Milena M Santric-Milicevic acknowledges support from the Ministry of Education, Science and Technological Development of the Republic of Serbia (Contract No. 175087). Rodrigo Sarmiento-Suarez acknowledges institutional support from University of Applied and Environmental Sciences in Bogota, Colombia, and Carlos III Institute of Health in Madrid, Spain. Maria Ines Schmidt acknowledges grants from the Foundation for the Support of Research of the State of Rio Grande do Sul (IATS and PrInt) and the Brazilian Ministry of Health. Sheikh Mohammed Shariful Islam acknowledges a fellowship from the National Heart Foundation of Australia and Deakin University. Aziz Sheikh acknowledges support from Health Data Research UK. Kenji Shibuya acknowledges Japan Ministry of Education, Culture, Sports, Science and Technology. Joan B Soriano acknowledges support by Centro de Investigacion en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain. Rafael Tabares-Seisdedos acknowledges partial support from grant PI17/00719 from ISCIII-FEDER. Santosh Kumar Tadakamadla acknowledges support from the National Health and Medical Research Council Early Career Fellowship, Australia. Marcello Tonelli acknowledges the David Freeze Chair in Health Services Research at the University of Calgary, AB, Canada. ; "Peer Reviewed"

Introduction of new forms of international cooperation, namely, electronic cross-border cooperation, is one of the priority directions of development of the world community. Electronic cross-border co-operation, including the use of cross-border trusted services, needs legislative regulation today. One of the locomotives of the international law-making process in the field of electronic trust services, electronic signatures is the United Nations Commission on International Trade Law, the International Chamber of Commerce and the Economic Commission for Europe (UNCITRAL, Commission). UNCITRAL approved the Model Law on Electronic Commerce and the Model Law on Electronic Signatures with a Guide to Enactment 2001. These legal acts became the classic basis for the creation of normative and legal acts of almost all countries in the field of e-commerce and electronic signature, laid the general principles of cross-border recognition of certificates of electronic digital signature. Starting in 2014, the UNCITRAL Working Group IV on e-Commerce has taken steps to address legal issues related to the management of identity and trust services. UNCITRAL is considering the process of legal recognition of trust services and digital signatures as a requirement for identifying legal requirements and establishing relevant substantive law in any jurisdictional system.However, at the current stage of development of international and national law in the area of using trust services and digital signatures in the cross-border regime, a number of global problems remain unresolved. The problem of terminology. The problem lies in the fact that national laws or international laws contain a set of concepts and definitions that are significantly different and sometimes of an overly technical nature, which complicates the perception of ordinary citizens. The problem of credential as a component of a digital signature and trust services. As you know, the key components of a digital signature are subscriber data, which is considered as digital credentials. To date, no legislative act addresses the issues of cross-border recognition of digital credentials, namely: who should hold such recognition, which party they should be recognized as the purpose of such mutual recognition, which features should be available for mutual recognition, which restrictions may apply during mutual recognition. Also, outside the scope of legal regulation, there is currently a problem of the mutual recognition of identity data of legal entities, digital devices or digital objects. The problem of trust in electronic services and digital signatures. The possibility of introducing technical mechanisms for ensuring the reliability of trust services exists and can be implemented promptly. However, today there are no international legal mechanisms guaranteeing a certain level and standards of trust in digital services of one of the parties exchanging such services. In many national identification systems, including in Ukraine, so-called "levels of security of trust" are defined as in the European Union ("low", "high" and "basic"). While four levels of trust are used in the United States and in some other countries. The problem of cross-border interoperability. States with different legal culture traditionally diverge in the technical and legal assessment of digital signatures. Common Laws (United States, United Kingdom) do not impose specific technical and legal requirements for a digital signature, nor does it require the mandatory provision of a digital signature at the same time by all parties to the trust service or electronic document. In this case, an electronic signature may be created by anyone and by any technology. In Roman-Germanic legal systems (mainly in European countries), where the legal doctrine traditionally played an essential role, another concept of digital signature has developed. In order to address these issues, Working Group IV, the United Nations Commission on International Trade Law, the International Chamber of Commerce and the Economic Commission for Europe, with the participation of many countries of the world, are exploring the prospects for legal regulation of the recognition of cross-border trust services and digital signatures through the development of common, standardized international legal acts. In its activities, UNCITRAL plans to explore the experience of several projects in the field of electronic trust services: – European Commission, Regulation (EC) No. 910/2014 of the European Parliament and of the Council of 23 July 2014 on electronic identification and trusted services for electronic transactions within the internal market and repealing Directive 1999/93/EC; – The Eurasian Economic Union, the Eurasian Economic Union Treaty and the Concept for the use of services and legally significant electronic documents in inter-state information interaction; – Asia-Pacific Region, Pan-Asian Alliance for Electronic Commerce Development. Also, Working Group IV examines the existing international instruments aimed at ensuring the mutual recognition of transnational legal effects in the paper environment, such as the Convention, which abolishes the requirement for legalization of foreign official documents "Convention on Apostille" (The Hague, October 5, 1961) and the Protocol on the Uniform Order acting on behalf of the executing authority (Washington, February 17, 1940), which may include appropriate recommendations for minimum elements for the cross-border mutual recognition of UID and trust services. The issue of legal recognition of cross-border trust services has received sufficient attention from different countries. Thus, the Russian Federation proposed a project "Improving the Identity Management System in the Use of Cross-Border Confidence and Common Trust Infrastructure in the Application of Cross-Border Electronic Commerce Agreements". The project is based on the model defined in the Model Law "On Transborder Information Exchange of Electronic Documents" of November 25, 2016. According to the project, it is proposed to create a large cluster of vertically integrated "cross-border trust", which will have three levels of electronic trust services (basic, medium, high). The cluster can have a single international regulator, regulators of intergovernmental unions and national regulators of digital trust services and digital signatures. It is also envisaged to introduce legal levels of regulation of digital trusted services on one or many domain-based basis with the involvement of a third independent trust party, as well as the unification of international and national regulatory frameworks. Instead, the United States considers it necessary in the near future to consider the issue of legal recognition of identification information that has been authenticated in connection with a commercial transaction, namely, that it is a legal recognition of its purpose, requirements, legal support, etc. The proposals of Austria, Belgium, Italy, the United Kingdom of Great Britain and the European Union concern the possibility of establishing agreed levels of security, which are provided through trust services: the first level – with the use of unskilled trust services. The second level with the use of qualified trusted services. The second level of legal consequences will include assimilation, presumption, transfer of the burden of proof to the opposing side, as well as the principle of mutual cross-border recognition for trusted services with the same level of security. Ukraine, as an active member of the global digitalization process, is taking some steps towards updating the legislation on digital signatures and trust services, namely the introduction of the new Law of Ukraine "On Electronic Trust Services". Ukraine, by amending existing legislation, adapts the regulatory framework in accordance with Regulation (EC) No910/2014 of the European Parliament and of the Council of 23 July 2014 on electronic identification and trusted services for electronic transactions within the internal market and repealing Directive 1999/93/EU. Today, there are many national and regional concepts and initiatives in the field of trust services, which have already been well developed. They can identify the relevant issues and can serve as a basis for developing an appropriate legal framework at the international level that could be transferred to various existing legal systems. The UNCITRAL Working Group IV on e-Commerce is implementing measures aimed at achieving the following objectives: – promotion of the development of international trade law and the satisfaction of the needs of economic actors in instruments that provide legal certainty for electronic transactions committed by them; – facilitating the harmonization of new legal aspects of projects, within which these issues are currently being resolved at the national or international level, to the more specific and functional content of the general requirements formulated in the current texts of UNCITRAL; – establishing a common legal framework for trust services and digital signatures, including relevant provisions aimed at developing international cross-border operational cooperation in the legal and technical fields. It is expedient for law-makers of Ukraine to take into account the world experience in developing normative legal acts regulating the sphere of trust services and digital signatures, including in the cross-border regime. ; В статье проанализирован законодательный опыт правового регулирования общественных отношений в сфере цифровой подписи и электронных доверительных услуг Комиссии ООН по международному торговому праву Международной торговой палаты и Европейской экономической комиссии UNCITRAL. Изучаются перспективы правового регулирования признания трансграничных доверительных услуг цифровых подписей путем разработки общих, стандартизированных международных правовых актов Рабочей группой IV Комиссии, а также при участии многих стран мира. На сегодня в ЮНСИТРАЛ формируется общее представление решения проблемы трансграничного признания иностранных цифровых подписей и электронных доверительных услуг на основе условия применения хотя бы одного из доктринальных толкований и наличия двух уровней безопасности. Изучено предложение Российской Федерации о введении проекта «Совершенствование системы управления идентификационными данными при использовании трансграничного пространства доверия и общей инфраструктуры доверия в применении к трансграничным электронным коммерческих сделкам». Изучены предложения Австрии, Бельгии, Италии, Соединенного Королевства Великобритании и Европейского Союза относительно возможности установления согласованных уровней безопасности, которые обеспечиваются с помощью доверительных услуг и уровней правовых последствий. Также рассмотрены предложения по применению принципов взаимного трансграничного признания для доверительных услуг, имеющих одинаковый уровень безопасности, и применению правового режима ответственности для квалифицированных поставщиков доверительных услуг. Осуществлен обзор проблемы трансграничного использования цифровых подписей и электронных доверительных услуг, присущих странам с разной юрисдикцией. Исследованы перспективные направления межгосударственного урегулирования сферы цифровых подписей и электронных доверительных услуг на основе примеров и предложений отдельных стран. ; У статті проаналізовано законодавчий досвід правового регулювання суспільних відносин у сфері цифрового підпису й електронних довірчих послуг Комісії ООН із міжнародного торговельного права Міжнародної торгової палати і Європейської економічної комісії UNCITRAL. Вивчаються перспективи правового регулювання визнання транскордонних довірчих послуг і цифрових підписів шляхом розроблення загальних, стандартизованих міжнародних правових актів Робочою групою IV Комісії, а також за участі багатьох країн світу. Сьогодні в ЮНСІТРАЛ формується загальне уявлення вирішення проблеми транскордонного визнання іноземних цифрових підписів та електронних довірчих послуг на основі умови застосування хоча б одного з доктринальних тлумачень і наявності двох рівнів безпеки. Опрацьовано пропозицію Російської Федерації щодо запровадження проекту «Вдосконалення системи управління ідентифікаційними даними під час використання транскордонного простору довіри й загальної інфраструктури довіри в застосуванні до транскордонних електронних комерційних угод». Вивчено пропозиції Австрії, Бельгії, Італії, Сполученого Королівства Великобританії та Європейського Союзу стосовно можливості встановлення узгоджених рівнів безпеки, які забезпечуються за допомогою довірчих послуг, і рівнів правових наслідків. Також розглянуто пропозиції щодо застосування принципів взаємного транскордонного визнання для довірчих послуг, що мають однаковий рівень безпеки, і застосування правового режиму відповідальності для кваліфікованих постачальників довірчих послуг. Узагальнено проблеми транскордонного використання цифрових підписів та електронних довірчих послуг, притаманні країнам із різною юрисдикцією. Досліджені перспективні напрями міждержавного врегулювання сфери цифрових підписів та електронних довірчих послуг на основі прикладів і пропозицій окремих країн.

Tropische Entwaldung und Waldschädigung (Degradation) trägt zu mehr als 20% zu den global emittierten Treibhausgasen bei. Entwaldung und ihre Auswirkungen können leichter mit Satellitenbildern abgeschätzt werden. Was Waldschädigung anbelangt, ist es schwierig, mit den aktuellen Satellitenbild-Auflösungen Abholzung und Biomasse-Schäden, die daraus resultieren, genau zu evaluieren, obwohl Waldschädigung wesentlich zu den Kohlenstoff-Emissionen in den Tropen beiträgt. Mit zunehmendem CO2-Gehalt in der Atmosphäre besteht ein dringender Bedarf an zuverlässigen Schätzungen von Biomasse und Kohlenstoff-vorräten in den tropischen Wäldern, ganz besonders in Afrika, wo der Datenmangel erheblich ist. Feuchte Tropenwälder speichern große Mengen an Kohlenstoff und benötigen genaue allometrischen Regressionen für deren Schätzungen. In Afrika hat die Abwesenheit von artspezifischen oder artübergreifenden allometrischen Gleichungen zum breiten Einsatz der pan-feucht-tropischen Gleichungen zur Baum-Biomasse Abschätzung geführt. Dieser Mangel an Informationen hat viele Diskussionen über die Richtigkeit dieser Daten angestoßen, da die Gleichungen aus Biomasse, die außerhalb Afrikas gesammelt wurde, abgeleitet wurden. Die Entwicklung von ortsspezifischen Gleichungen und pan-feucht-tropischen Gleichungen, unter Einschluß von Daten aus Afrika, wird für die meisten Ökologen immer wichtiger, um die genaue Schätzung dieses Beitrags zu erweitern, der für Anpassung und Klimaschutz-Strategien notwendig ist. Allometrische Gleichungen sind Schlüssel-Werkzeuge für die Szenarien des Klimawandels, da sie für die Abschätzung von Biomasse und Kohlenstoff-Pool auf lokaler, regionaler und globaler Ebene verwendet werden. Informationen zur Netto-Primärproduktion (NPP), die sich aus direkten Biomasse Feldmessungen ergeben, sind in diesem Zusammenhang von entscheidender Bedeutung, um zu wissen, wie die Waldökosysteme durch den Klimawandel betroffen sein werden und auch um Eddy-Kovarianz-Messungen zu kalibrieren. Das übergeordnete Ziel dieser Studie war es, einen wissenschaftlichen Beitrag zur Anpassung oder Schadenseindämmung von feuchten tropischen Wäldern auf die Auswirkungen des Klimawandels zu erstellen. Die spezifischen Ziele waren: (1) Analyse der Bestandesentwicklung eines Waldes im östlichen Kamerun und Diskussion einer Methodik zur Schätzung der potenziellen Kohlendioxidemissionen oder zur Eindämmung von Waldschäden. (2) Entwicklung allometrischer Gleichungen für die genaue Schätzung der Biomassen und Kohlenstoffvorräte in feuchten Wäldern in Kamerun und auch in Afrika. (3) Schätzung der Kohlenstoffspeicher und der Netto-Primärproduktion (NPP) und ihre räumliche Verteilung auf verschiedene Schichten und Landnutzungstypen des Campo-Ma'an Bereichwaldes in Kamerun. Diese Dissertation präsentiert Ergebnisse aus zwei Feldstudien, durchgeführt in der Nachbarschaft von Yokadouma im östlichen Kamerun und auch in der Campo-Ma'an Wald im südlichen Kamerun. Die vorliegende, in Yokadouma durchgeführte Studie resultierte in einer Veröffentlichung, die Waldschädigung nach selektivem Holzeinschlag und deren Implikationen für REDD und die Kohlenstoff-Schätzungen ansprach. Um diese Situation anzugehen wurde die Post-logging-Bestandsentwicklung eines semi-natürlichen Laubwaldes in Kamerun für einen Einschlagszyklus (30 Jahre) nach selektivem Holzeinschlag modelliert. Um zu simulieren wie verschiedene Management-Praktiken Einfluss auf die Post-logging-Bestandsdynamik haben, modelliert man, wie Änderungen des Mindest-Einschlags-durchmessers (MFD) Stammzahlen, Dichte, Grundfläche und die damit verbundene Kohlenstoff-Biomasse am Ende des Einschlagszyklus beeinflussen. Die in Campo-Ma'an durchgeführte Studie resultierte in zwei weiteren Artikeln. Der erste Artikel behandelt ortsspezifische und auch pan-feucht-tropische allometrische Gleichungen, die auch an anderen Standorten in feuchten tropischen Wäldern, wo es keine spezifischen allometrischen Gleichungen gibt, benutzt werden können. Diese Studie verwendet 91 destruktive Probebäume, um damit artübergreifende allometrische Gleichungen zu entwickeln, und zwar unter Anwendung verschiedener Eingangsgrößen wie Durchmesser, Durchmesser und Höhe, ein Produkt von Durchmesser und Höhe, und Holzdichte. Unsere Biomassedaten wurden zu 372 Biomassedaten aus verschiedenen feuchten tropischen Wälder in Asien und Südamerika hinzugefügt, um damit neue pan-feucht-tropische allometrische Regressionen zu entwickeln. Artspezifische- und artübergreifende Höhen-Durchmesser- Regressionsmodelle wurden auch entwickelt, um Höhen von 3833 Bäumen abzuschätzen. Der zweite Aufsatz verwendet unsere ortsspezifischen allometrischen Gleichungen, um oberirdische und unterirdische Biomasse- und Kohlenstoffvorräte zu schätzen. Die NPP wurde anhand der Wachstumsraten aus Baumringanalysen ermittelt. Eine Kohlenstoff-Biomasse-Karte wurde auch in dieser letzten Arbeit mit GIS-Technologie entwickelt, um Verteilungen der verschiedenen Nutzungen und Vegetationstypen darzustellen. Die wichtigsten Ergebnisse waren folgende: Waldschädigungs-Studien: Mit diesen geschätzten MFDs ermittelten wir bei 7% Fällungsschadensraten, dass sich die Stamm-Dichte von erntereifen Bäume von 12,3 (50,4 MgC ha-1) auf 6,7 (32,5 MgC ha-1) Bäume pro Hektar reduziert und sich die Zahl der bleibenden Bäume von 80 (18,9 MgC ha-1) auf 85,7 (36,8 MgC ha-1) Bäume pro Hektar erhöht. Dies entspricht einem vermiedenen Schaden von geschätzten 17,9 MgC ha-1. Wir fanden auch heraus, dass eine Erhöhung der Mortalität und Schadensintensität auch die Schädigung der Kohlenstoff-Biomasse erhöht in 30 Jahre, und zwar schätzungsweise auf 8,9 MgC ha-1 bei 10% oder auf 17,4 MgC ha-1 bei 15% Fällschaden. Diese Studie zeigt, dass die korrekte Bestimmung des MFD der gefällten Arten (unter Berücksichtigung ihrer Fähigkeit zur Rekonstitution am Ende des Fällungszyklus im Zusammenhang mit Reduced Impact Logging (RIL)) die Freisetzung von bis zu 35 MgC ha-1 vermeiden kann. Diese Schätzungen könnten erreicht werden, wenn eine Kombination von Politik und Maßnahmen erfolgt, die die Überwachung der Waldentwicklung nach dem Einschlag beinhaltet. Allometrische Gleichungen Mit nur dem Durchmesser als Eingangsgröße schätzt das artenübergreifende Regressionsmodell die oberirdische Biomasse des untersuchten Ortes mit einem mittleren Fehler von 7,4%. Hinzufügung von Höhe oder Holzdichte trug nicht wesentlich zur Verbesserung der Schätzungen bei. Mit den drei Variablen zusammen verbesserte sich die Genauigkeit auf einen mittleren Fehler von 3,4%. Für allgemeine allometrische Gleichungen war die Baumhöhe eine gute Prädiktor-Variable. Die beste pan-feucht-tropische Gleichung erhielt man, wenn die drei Variablen hinzugefügt wurden, gefolgt durch jene, die Durchmesser und Höhe umfasste. Diese Studie liefert Höhen-Durchmesser-Beziehungen und Holz dichten von 31 Arten. Die pan-feucht-tropische Gleichung durch Chave et al. (2005) schätzt die gesamte oberirdische Biomasse von verschiedenen Standorte mit einem mittleren Fehler von 20,3%, gefolgt von den in der vorliegenden Studie entwickelten Gleichungen mit einem mittleren Fehler von 29,5%. Biomasse, Kohle, NPP Die Kohlenstoff-Biomasse betrug im Durchschnitt 264 Mg ha-1. Diese Schätzung beinhaltet oberirdischen Kohlenstoff und wurzel-organischen Kohlenstoff des Bodens bis zu 30 cm Tiefe. Dieser Wert variiert von 231 Mg ha-1 an Kohlenstoff in Agroforstwäldern bis zu 283 Mg ha-1 an Kohlenstoff in bewirtschafteten Wäldern und bis zu 278 Mg ha-1 an Kohlenstoff in einem Nationalpark. Die Kohlenstoff-NPP variierte pro Jahr von 2542 kg ha-1 in Agroforstwäldern bis zu 2787 kg ha-1 in bewirtschafteten Wäldern und bis zu 2849 kg ha-1 Jahr-1 im Nationalpark. Unsere NPP Werte beinhalten keine Fein-Streu, Kohlenstoffverluste durch Verbraucher und Emissionen von flüchtigen organischen Verbindungen. Wir glauben, dass unsere Studie nicht nur die entsprechenden Schätzungen von Biomasse, Kohlenstoff-Pools und NPP liefert, sondern auch eine geeignete Methode darstellt, um für diese Komponenten und die damit verbundenen Unsicherheiten generell Schätzungen zu liefern. ; Tropical deforestation and forest degradation contributes to more than 20% of the global greenhouse gases emitted. Deforestation and its impacts can be more easily estimated with satellite images. Concerning forest degradation, it is difficult with the actual satellite image resolutions to evaluate accurately logging and biomass damage resulting from this activity though it contributes substantially to carbon emissions in the tropics. With increasing CO2 in the atmosphere, there is an urgent need of reliable biomass estimates and carbon pools in tropical forests, most especially in Africa where there is a serious lack of data. Moist tropical forests store large amounts of carbon and need accurate allometric regressions for their estimation. In Africa the absence of species-specific or mixed-species allometric equations has lead to a broad use of pan moist tropical equations to estimate tree biomass. This lack of information has raised many discussions on the accuracy of these data, since equations were derived from biomass collected outside Africa. Developing site-specific equations and pan-moist tropical equations including data from Africa is becoming very important for most ecologists for accurate estimations of this contribution extend, necessary for adaptation and mitigation strategies on climate change impacts. Allometric equations are key tools for climate change scenarios since they are used for estimating biomass and carbon pool at local, regional and world level. Information on net primary production (NPP) resulting from direct biomass field measurements of annual tree ring width is crucial in this context, to know how forest ecosystems will grow in the future with their possible impacts on carbon pools and fluxes and also to calibrate eddy covariance measurements. The overall objective of this study was to provide a scientific contribution for adaptation or mitigation of moist tropical forests on climate change impacts. The specific objectives were to (1) analyze the stand development of a forest in the eastern Cameroon and discuss a methodology for estimating the potential carbon emissions or reductions from forest degradation, (2) develop allometric equations for accurate estimations of biomass and carbon pools in moist forests in Cameroon and also in Africa, (3) estimate carbon pools and Net Primary Productivity (NPP) and their spatial distribution on different strata and land use types of the Campo-Ma an area forest in Cameroon. This dissertation presents results from two field studies conducted at the neighbourhood of Yokadouma in the eastern Cameroon and also in the Campo-Ma an forest in the southern Cameroon. The study conducted at Yokadouma resulted in a paper addressing forest degradation after selective logging and its implications for REDD and carbon pools and flux estimations. To address this situation, a post-logging stand development of a semi-deciduous natural forest in Cameroon was modelled for one felling cycle (30 years) after selective logging. To simulate how different management practices influence post-logging forest dynamics, we modelled how changes in the minimum felling diameter (MFD) affect stem density, basal area and the related carbon biomass at the end of the felling cycle. The study conducted in Campo-Ma an resulted in two other projected articles. The first article addressed site-specific allometric equations and also pan-moist tropical equations which can be used at other locations in moist tropical forests where there are no specific allometric equations. We used for this study 91 destructive sample trees to develop mixed-species allometric equations applying different input variables such as diameter, diameter and height, product of diameter and height, and wood density. Our biomass data were added to 372 biomass data collected across different moist tropical forests in Asia and South America to develop new pan moist tropical allometric regressions. Species-specific and mixed-species height diameter regression equations were also developed to estimate heights using 3833 trees. The second projected article used our site-specific allometric equations to estimate aboveground and belowground biomass and carbon pools. The NPP was estimated using the growth rates obtained from tree ring analysis. A carbon biomass map was also developed in this last paper using GIS technology to show the distribution in the different land uses and vegetation types. The main findings were the following: Forest degradation studies: With these MFDs estimated, at 7% logging damage rate, we found that the stem density of harvestable trees reduces from 12.3 (50.4 MgC ha-1) to 6.7 (32.5 MgC ha-1) trees per ha and the number of residual trees increases from 80 (18.9 MgC ha-1) to 85.7 (36.8 MgC ha-1) trees per ha. This corresponds to an avoided damage estimated at 17.9 MgC ha-1. We also found that increasing mortality and damage intensity also increases the damage on carbon biomass estimated after a felling cycle of 30 years to be 8.9 MgC ha-1 at 10% or to be 17.4 MgC ha-1 at 15% logging damage. This study shows that proper determination of MFD of logged species taking into consideration their capacity of reconstitution at the end of the felling cycle associated with Reduced Impact Logging (RIL) can avoid up to 35 MgC ha-1. These estimations could be achieved if there is a combination of Policy and Measures allowing monitoring of forest development after logging. Allomeric equations Using only tree diameter as input variable, the mixed-species regression equation estimates the aboveground biomass of the study site with an average error of ±7.4%. Adding height or wood density did not improve significantly the estimations. Using the three variables together improved the precision with an average error of ±3.4%. For general allometric equations tree height was a good predictor variable. The best pan moist tropical equation was obtained when the three variables were added together followed by the one which includes diameter and height. This study provides height-diameter relationships and wood density of 31 species. The pan moist tropical equation developed by Chave et al. (2005), estimates total aboveground biomass across different sites with an average error of ±20.3% followed by equations developed in the present study with an average error of ±29.5%. Biomass, carbon, NPP The carbon biomass of Campo-Ma an forest was on average 264 Mg ha 1. This estimate includes aboveground carbon, root carbon and soil organic carbon down to 30 cm depth. This value varied from 231 Mg ha 1 of carbon in Agro-Forests to 283 Mg ha 1 of carbon in Managed Forests and to 278 Mg ha 1 of carbon in National Park. The carbon NPP varied from 2542 kg ha 1 year 1 in Agro-Forests to 2787 kg ha 1 year 1 in Managed Forests and to 2849 kg ha 1 year 1 in National Park. Our NPP values do not include fine litterfall, carbon losses to consumers and emission of volatile organic compounds. We believe that our study provides not only appropriate estimate of biomass, carbon pools and NPP, but also an appropriate methodology to estimate these components and the related uncertainty.

학위논문(박사)--서울대학교 대학원 :의과대학 의학과,2020. 2. 강영호. ; 1. Background Low-quality services of emergency medical institutions, unclear function of institution classification, and overcrowding of emergency departments (ED) of regional emergency medical centers (regional centers) have been major problems in the Korean emergency medical services system (EMSS). In 2015, the Middle East Respiratory Syndrome (MERS) outbreak spread from patients waiting for hospitalization in the overcrowded ED. The MERS outbreak was an event that revealed the vulnerability of EMSS and opened the policy window to solve the problem of EMSS in Korea. Several policies for EMSS improvement were implemented after the 2015 MERS outbreak focusing the improvement of emergency medical services (EMS) delivery system and ED infection control. This study investigates the policy processes for improving emergency EMSS and infection control program after the MERS outbreak. The purpose of this study was to examine the policy processes regarding EMSS from the view of policy actors and draw lessons for improving the EMSS in Korea. 2. Methods A mixed method was utilized to identify and explain the complex subject of the policy processes of Korean EMSS during and after the MERS outbreak in 2015. As a quantitative study, changes in EMSS after MERS were investigated according to the WHO's model of a national health system infrastructure. Literature review and data analysis of Korean Health Insurance Service (NHIS) database were conducted. In Korea, the NHIS covers all citizens. A quantitative analysis was performed on 16,965,755 cases using ED during 2014-2016. In-depth interviews were conducted on 30 experts, who were involved in the emergency medical policy process, including clinicians, policy experts, and hospital management experts. The total interview time was 55 hours and 4 minutes. Changes in EMSS and the policy process after the MERS outbreak were evaluated from the view of policy actors. In this study, quantitative data was interpreted qualitatively, and independent qualitative evaluation was conducted, as well. Therefore, this research is a mixed-methods study focusing on qualitative research. SAS version 9.4 was used for the quantitative analysis and NVivo 12.0 was used for the qualitative analysis. 3. Results The quantitative analysis results showed that in the area of EMS delivery system, the human resource of ED and number of regional centers have been increased and facility, equipment, and manpower standards have been revised in order to expand emergency medical resources. As a result, the number of medical personnel and emergency intensive care units in regional centers increased and profitability of ED improved as well. The number of monthly ED visits temporarily decreased during the MERS outbreak but then recovered afterward. As ED overcrowding indicators were emphasized in the evaluation of EMS institutions, monthly mean ED length of stay of regional centers was decreased. However, despite the emphasis on providing critical care, transfer rate of severe emergency patients was not decreased. In the policy processes of EMS, experts evaluated that EMS delivery system was set up as a pseudo-agenda and exploration and comparison of policy alternatives were not sufficiently carried out. As a result, the physicians did not comply with the policy implementation and policy goals were not achieved. In the area of ED infection control program, the human resources for infection control and the number of isolation unit of ED were increased. Budgets for emerging infectious disease management were increased and profitability of infection control was also improved. The EMS Act was revised to respond to emerging infectious diseases and indicators related to infection control were strengthened in evaluation of EMS institutions. In the qualitative research, experts said that since the ED infection control program was such an intuitive and obvious problem, it was easy to become a policy-agenda. Despite the resistance of small hospitals, ED infection control program was implemented by powerful policy measures such as the revision of the Law. As a result, policy goals of expanding the infection control resources and improving the infection management environment were able to be achieved. From results of observing EMS policy process, the following characteristics of policy actors were found. First, there was difference of opinions within the physician subgroup as well as between government and medical professionals. ED staff, other department staff, and hospital executives, who have different views on policy alternatives could have all served as veto points in the policy process. Second, while the EMSS expert organization, which was an unofficial participant in the emergency medical policy process, could have played both roles of cause group and sectional group in the policy process, their sectional position has been emphasized, thereby weakening their insider status during policy process. Third, policy actors understood the publicness of EMS differently in terms of its ownership and function. The ED staff insisted that government support is needed because emergency medical care is based on public interest, however, some staffs were unwilling to provide less profitable cares, leading to conflict. Main characteristics of the emergency medical policy process that made it difficult to successfully implement are as follows: First, there was lack of consideration regarding variation of EMSS in Korea, such as distribution of medical resources among different regions, incentives to hospitals, and understanding of functional variations in ED. Second, the problem of the EMS delivery system was a problem of the low quality of emergency medical care. Third, the lack of professionalism in some physicians has lowered the capacity of emergency medical care, as well as trust between patient and doctor, therefore made the problem more difficult to solve. 4. Discussion Based on the analysis of the policy processes of the EMSS after the MERS outbreak in Korea, following lessons are suggested. First, setting the goals of EMS from the perspectives of citizen is warranted. The final performance goal should focus on improving health status of citizen and satisfaction with emergency medical care. Second, to close the gaps among policy actors in understanding policy content and policy process, actors should work together to explore the root causes of the problems and establish a policy agenda together. Third, a policy alternative should be causal in solving the problems in EMSS considering variation of EMS. Fourth, compliance with policies could be secured by internal persuasion among policy actors with proper incentives and reasonable punishment, especially EMSS expert organization. Fifth, policy outcomes should be evaluated based on both policy output and side effects together to identify policy impact. Sixth, policy governance regarding EMSS should be established and the roles of EMSS expert organization should be strengthened as the cause group rather than sectional group. This study examined the emergency medical policy processes from the view of policy actors through the 2015 MERS outbreak in Korea. The improvement of EMSS should be based on understanding of the emergency medical policy process and policy actors. ; 1. 서론 응급의료기관의 응급환자 진료 역량부족과 불명확한 종별 기능 구분, 일부 응급실의 과밀화는 한국 응급의료체계(emergency medical services system, EMSS)의 고질적인 문제였다. 2015년 과밀화된 상급종합병원 응급실에서 입원대기 중이던 환자로부터 메르스(Middle East Respiratory Syndrome, MERS) 유행이 확산되었다. 메르스 유행은 우리나라 응급의료체계의 취약성이 드러난 사건이자 응급의료 문제를 해결할 수 있는 정책의 창이 열린 사건이었다. 정부는 메르스 유행 이후 여러 가지 응급의료 개선정책을 추진하였다. 이 연구는 취약한 응급의료 전달체계 하에서 응급환자 감염관리의 실패로 인해 메르스 유행이 발생했다는 점에 문제의식을 두었다. 그래서 응급의료 전달체계와 응급환자 감염관리 영역에서 메르스 유행 이후 이루어진 정책과정과 그로 인한 변화를 분석하였다. 응급의료 정책행위자의 관점에서 정책과정과 정책결과를 분석함으로써, 향후 응급의료 개선을 위한 정책과정에서 고려해야 할 점을 도출하는 것이 이 연구의 목적이다. 2. 연구방법 메르스 유행 이후 응급의료 정책과정 분석이라는 복잡한 주제를 파악하고 설명하기 위하여 혼합연구방법(Mixed methods research)을 사용하였다. 양적연구로 문헌고찰과 국민건강보험공단 자료 분석을 통해 메르스 유행 이후 응급의료체계의 변화를 보건의료체계의 구성요소별로 조사하였다. 한국은 1989년 전국민 의료보험제도를 도입하여 전 국민이 국민건강보험에 가입되어 있는 국가이다. 메르스 유행 전후 응급실 이용 변화를 조사하기 위하여 국민건강보험공단 DB의 2014-2016년 응급실 이용 진료건 16,965,755건을 분석하였다. 질적연구로 응급실 의료진, 정책 전문가, 병원 경영진 등 응급의료 정책과정의 관련 전문가 30명을 대상으로 심층면접을 수행하였다 전체 심층면접 분량은 55시간 4분이었다. 심층면접을 통해 정책 행위자의 관점에서 메르스 이후 이루어진 응급의료 정책과정을 고찰하고, 응급의료체계의 변화를 조사하였다. 양적연구 결과를 질적연구로 해석하고 질적연구로 독자적인 분석을 수행하여, 이 연구는 질적연구가 중심이 된 혼합연구로 볼 수 있다. 양적연구의 분석에는 SAS version 9.4를 사용하였고, 질적연구 분석은 NVivo 12.0을 사용하였다. 3. 연구결과 응급의료 전달체계 영역에서 응급의료 자원을 확대하기 위해 권역응급의료센터(권역센터)가 확대되고 시설·장비·인력기준과 관련 수가가 개정되었다. 그 결과 권역센터의 의료인력과 응급중환자실 병상 수가 증가하고 수익성이 개선되었다. 달빛어린이병원 사업을 확장한 결과 달빛어린이병원 수도 증가하였다. 응급실 과밀화를 완화하기 위해 응급의료기관 평가에 재실시간 지표를 수가연동지표로 도입하고 응급의료에 관한 법률에 응급의료센터 24시간 이상 재실환자 관리 규정을 넣었다. 그 결과 응급실 월별 방문환자 수는 2015년 메르스 유행 당시 일시적으로 감소한 후 지속 증가 추세이나, 권역센터 응급환자의 월별 재실시간 평균은 2014-2016년 기간 동안 감소 추세를 보였다. 응급의료기관의 응급환자 진료역량을 강화하기 위해 응급의료기관 평가에 중증해당환자 최종치료 제공 관련 지표를 강화하였으나 2017-2018년 기간 중증응급환자의 전원율은 개선되지 않았다. 전문가들은 응급의료 전달체계 개선은 위장의제(pseudo agenda)로 설정되어 정책대안 탐색과 비교평가가 충분히 이루어지지 않았으며 점중주의적으로 쓰레기통 모형의 정책결정이 이루어졌다고 평가하였다. 그 결과 정책대상집단인 의사들은 정책집행에 순응하지 않았고, 정책은 집행 후에도 정책목표를 달성하지 못했다. 응급환자의 감염관리 영역에서 권역센터 시설·장비·인력기준과 감염관리실 설치기준 및 인력기준이 개정되어 응급실 감염관리 자원이 확대되었다. 정부는 응급실 방문객 관리를 도입하고, 감염예방관리료 등 감염관리 관련 건강보험 수가를 신설하였으며, 신종감염병 대응 관련 법률 등 감염관리 관련 법률을 개정하여 응급실 감염관리 여건을 개선하였다. 전문가들은 응급환자 감염관리는 직관적이고 명확한 문제라는 특성이 있어 병원 내 감염관리 강화로 의제화되기 쉬웠다고 평가하였다. 감염관리 개선정책은 보호적 성격을 가진 규제정책으로 집행 과정에서 중소병원을 중심으로 일부 병원의 반발이 있었다. 그러나 응급의료에 관한 법률 개정과 같은 강력한 정책수단을 사용하여 집행된 결과, 응급실 감염관리 자원확대와 감염관리 환경개선이라는 정책목표를 달성하였다. 응급의료 정책행위자들의 관점에서 응급의료 정책과정을 관찰한 결과 다음과 같은 정책행위자의 특징을 발견하였다. 첫번째, 정부 전문가와 의료진 전문가 사이뿐 아니라 의사 하위집단 내에서도 견해 차이가 존재하였다. 정책대안에 대해 다른 견해를 가지고 있는 응급실 의료진, 배후진료과 의료진, 병원 경영진은 정책과정에서 모두 거부점(veto point)으로 작용할 수 있었다. 두번째, 응급의료 정책과정의 비공식적 참여자인 응급의료 관련 전문학회는 정책과정에서 대의집단이자 파벌집단의 역할을 동시에 수행할 수 있으나, 정책과정에서 파벌집단의 역할이 강조됨으로써 내부자의 지위가 약화되었다. 세번째, 응급의료의 공공성에 대하여 소유주체 기준에 따른 공공성과 기능에 따른 공공성 개념이 혼재되어 사용되며 서로 다른 공공성 개념에 따른 정책행위자간 갈등이 발생하였다. 응급실 의료진은 응급의료가 공공의 이익을 실현하는 의료영역이므로 정부 지원이 필요하다고 주장했으나 일부 의료진은 수익성이 낮은 진료를 기피하는 모습을 보여 정부 전문가와 의견 차이를 보였다. 응급의료 정책과정의 성공적 추진을 어렵게 한 정책과정의 특징은 다음과 같다. 첫번째, 응급의료 정책과정에서 지역간 의료자원 분포, 병원에 작용하는 유인, 병원 내 응급실의 역할과 같은 응급의료에 존재하는 변이에 대한 고려가 부족했다. 두번째, 응급의료 전달체계 문제는 곧 응급의료기관의 취약한 응급환자 진료 역량의 문제였다. 세번째, 일부 의사들의 전문직업성(professionalism) 부족이 응급의료기관의 응급환자 진료 역량을 취약하게 하고, 환자-의사 사이 신뢰를 저하시켜 대형병원 쏠림현상을 악화시켰다. 4. 고찰 메르스 유행 이후 이루어진 응급의료 개선정책의 정책결과 분석과 정책과정에 대한 연구 결과를 근거로 하여 향후 응급의료 정책과정에 대하여 다음과 같이 제언한다. 첫번째, 국민의 관점에서 응급의료체계의 개선목표를 설정할 필요가 있다. 건강수준 향상과 응급의료 서비스에 대한 만족도 향상이라는 최종 성과목표가 개선정책의 목표로 설정되어야 한다. 두번째, 정책행위자의 인식 차이를 좁히기 위하여 여러 행위자가 함께 문제의 원인을 탐구하고 정책의제를 설정하는 과정이 필요하다. 세번째, 문제 해결에 인과성 있는 정책대안이 결정되어야 한다. 인과성 없는 정책대안은 정책이 집행되어도 정책문제를 해결하지 못한다. 네번째, 정책대상자의 순응을 확보할 필요가 있다. 유인과 처벌 이전에 전문가이자 정책대상자인 의사들에 대한 내면적 설득 과정이 필요하다. 다섯번째, 정책산물과 부수작용을 포괄하는 정책결과 평가가 필요하다. 여섯번째, 응급의료 정책 거버넌스를 확립하고 응급의료 관련 전문학회를 정책과정에 참여시켜 대의집단의 성격을 강화할 필요가 있다. 이 연구는 2015년 메르스 유행이라는 사건을 통해 응급의료 정책행위자들의 관점에서 우리나라 응급의료 정책과정을 고찰하였다. 응급의료 정책과정과 정책행위자에 대한 이해를 바탕으로 응급의료체계 개선을 추진해나가야 한다. ; I. 서 론 1 1. 연구 배경과 필요성 1 1) 한국 응급의료체계의 문제 1 2) 2015년 메르스 유행과 응급의료체계 4 3) 연구의 필요성 6 2. 연구 목적 10 II. 이론적 배경 12 1. 보건의료체계의 평가 12 1) WHO 보건의료체계의 구성요소 12 2) 보건의료체계 개혁을 위한 조종손잡이 14 2. 정책론 18 1) 정책과정의 이해 18 2) 응급의료 정책과정의 이해 25 III. 연구방법 35 1. 혼합방법 연구설계 35 2. 양적연구 방법 43 1) 양적 연구의 자료 수집 43 2) 양적 연구의 자료 분석 46 3. 질적연구 방법 54 1) 연구팀 구성 54 2) 심층면접 설계 55 3) 분석 방법 67 4. 혼합방법 연구의 통합 70 IV. 연구 결과 72 1. 양적연구 결과 72 1) 응급의료 전달체계 72 2) 응급환자의 감염관리 121 2. 질적연구 결과 134 1) 심층면접 참여자의 특성 134 2) 응급의료 전달체계 137 3) 응급환자의 감염관리 249 3. 연구결과의 종합 297 1) 2015 메르스 유행의 응급의료체계에 대한 의의 297 2) 메르스 유행 이후 응급의료 정책과정 분석 298 3) 응급의료 정책과정의 특징 340 V. 논의 363 1. 응급의료 정책과정 고찰 363 2. 연구의 한계 380 3. 연구의 의의 383 1) 방법론적 의의 383 2) 정책적 의의 384 4. 연구의 결론 385 1) 메르스 유행 이후 응급의료 전달체계와 응급환자 감염관리의 변화 385 2) 응급의료 정책과정 고찰 386 3) 응급의료체계 개선을 위한 정책과정에의 시사점 388 VI. 참고문헌 390 ; Doctor