Health Care in North
Korea
Tiers of the systems
 Household or section doctors
 1 doctor per 130-150 households (rural and urban)
 Polyclinic (Ri or Dong)
 County hospitals
 Specialized units for nutrition, and TB
 Provincial hospitals
 National referral hospitals
 National health system management is rigidly centralized
 National health information is patently manipulated
National Maternity Hospital,
~equivalent in each province
County Hospital
Nutrition rehabilitation ward
County Hospital
Tuberculosis hospital
Nutrition rehabilitation ward
Felt by many to be serious
under reporting
County Hospital
County Hospital
Pyongyang Medical University
13
Key indicators
DPRK
ROK
67y (71 in 1990)
42*
55*
370
79y
5
5
22
Life time risk of death in pregnancy
World ranking
1:140
57
1:3700
167
Stunting children U5
Doctors/10,000
Nurses/10,000
Hospital beds/10,000
Populations >60 yrs
45%
33
41
132
9.6%
16
19
86
11.1%
Life Expectancy (birth)
Infant Mortality Rate/10,000
Under 5 Mortality Rate/10,000
Maternal Mortality Ratio
*unchanged since 1990
Health conditions
 Among children diarrhea and respiratory illness remain major







causes of death, and for newborns low birth weight (est 31%)
Childhood illness is complicated by intergenerational malnutrition
Exclusive breastfeeding has decreased substantially
Continuing widespread reports of death from starvation
Increasing problems with street children, and lack of health care
Malnutrition, hepatitis and TB reported commonly
 May underlie many adult deaths reported from starvation
 TB drug supply is intermittent, giving rise to drug resistant TB
 General collapses of water and sanitation systems
Increasing reports of methamphetamine abuse inside DPRK
High vaccination coverage reports, probably accurate
Health conditions
 Among children diarrhea and respiratory illness remain major







causes of death, and for newborns low birth weight (est 31%)
Childhood illness is complicated by intergenerational malnutrition
Exclusive breastfeeding has decreased Malaria
substantially
5% Worldwide
Continuing reports of deathOther
from 32%
starvation from much
of DPRK
Measles
5%
Increasing problems with street children, and lack of health care
Diarrhea 17%
Malnutrition, hepatitis and TB reported commonly
Malnutrition
a
 May underlie many adult deaths reported
from
starvation
factor in 54%
 TB drug supply is intermittent, givingofrise
to drug resistant TB
<5 deaths
 General collapses of water and sanitation systems
Increasing reports of methamphetamine abuse inside DPRK
Peri-natalprobably accurate
High vaccination coverage reports,
Acute respiratory
18%
infections (ARI) 19%
Health conditions
 Among children diarrhea and respiratory illness remain major







causes of death, and newborns low birth weight (est at 31%)
Childhood illness is complicated by intergenerational malnutrition
Exclusive breastfeeding has decreased Malaria
substantially
5% Worldwide
Continuing reports of deathOther
from 32%
starvation from much
of DPRK
Measles
5%
Increasing problems with street children, and lack of health care
Diarrhea 17%
Malnutrition, hepatitis and TB reported commonly
Malnutrition
a
 May
underlie
many
adult
deaths
reported
from
starvation
factor in 54%
55% mothers
 TB
drug supply is intermittent, givingofrise
to drug resistant TB
<5 deaths
underweight;
 General
collapses of water and sanitation systems
35-61% anemic
(UNICEF)
Increasing reports of methamphetamine abuse inside DPRK
Peri-natalprobably accurate
High vaccination coverage reports,
Acute respiratory
18%
infections (ARI) 19%
Traditional medicines
 Hospitals and schools reportedly grow traditional medicines as


income generating activities
Factory reportedly constructed in Rajin for processing and
export to China
Use in North Korea appears common
H1N1
 Was a major problem in DPRK in early 2010
 Many deaths, probably complicated by malnutrition
 Increased seasonal flu occurred at the same time
 Draconian quarantine procedures cut apartment residents off
from food
 Schools were closed, producing problems for working
parents
 Tamiflu medications donated by South Korea was restricted
to Pyongyang
Hospitals
 Hospitals reached their peak c1960; little investment since 1990
 Critical shortage of essential drugs, UNICEF & WHO supply
 Evidence that drugs supplied are being sold by doctors and




staff of hospitals and pharmaceutical factory workers
 Chinese pharmaceuticals from markets usual form of treatment
 Payment widely demanded for hospitalization
and for various treatments
Absence of x-ray filmwide use of fluoroscopy
Continuing deterioration of equipment
Water and sanitation provisions are poor
Electricity supply is intermittent
Health workers
 On paper staffing looks extensive
 Probably overstaffing exists
 Excess hospital beds by current standards
 Human resources centrally managed, and poor planning
 Largely isolated from international trends and protocols
 Few textbooks available
 Little continuing medical education
 Medical students must spend 4-5 hours a day growing food
 Doctors and nurses must participate in any reconstruction work
 Quality of medical education is poor; almost no defectors can
pass South Korean exams
Health workers
 On paper staffing looks great
 Probably overstaffing exists
 Excess hospital beds by present standards
 Human resources centrally managed, and poor planning
 Largely isolated from international trends and protocols
 Few textbooks available
 Little continuing medical education
 Medical students must spend 4-5 hours a day growing food
 Doctors and nurses must participate in any reconstruction work
 Quality of medical education is poor; almost no defectors can
pass South Korean exams
Health structure
 Health structure in North Korea
 Section doctor, or family doctor is responsible for curative and



preventive care for 130 households
 Section doctor has 30-40 health volunteers to assist
Section clinic or Ri-clinic staffed by section doctors
 Some of these have inpatient beds
 Only 28% said this was the primary source of care
County or municipal hospital (212 counties)
 Most (66.8%) said this was their primary source of care
County Hospital
Chronic
shortage
of medicines
Provincial
hospital
(9 provinces)
25
Health systems research
 A 2004 study of Health Seeking Behavior
 What happens when people get sick in North Korea?
 What are common outpatient diseases?
 What are common inpatient diseases?
 What do people have to pay when they get sick?
 How do they pay?
 Interviews with 273 migrants recently (4 wks) arrived in China
26
Demographic Findings
 50.5% were male, average age was 40 years
 All had middle school education
 44% lived in urban areas
 88% of households had 4 or fewer members
 Most came from North Hamgyong Province
 Everyone had two jobs
 An official job—61% said they were unemployed

and 28% were factory workers
 An unofficial job—most popular was retail/food sales
64% of houses were less than 30m2 in size (18 ft x 18 ft)
27
Demographic Findings
 50.5% were male, average age was 40 years
 All had middle school education
 44% lived in urban areas
 88% of households had 4 or fewer members
 Most came from North Hamgyong Province
 Everyone had two jobs
 An official job—61% said they were unemployed

and 28% were factory workers
 An unofficial job—most popular was retail sales
64% of houses were less than 30m2 in size (18 ft x 18 ft)
28
Monthly Household
income (2004 NK won)
70
60
US$43
50
30
20
10
>8
00
0
0
<2
00
0
20
00
-3
99
9
40
00
-5
99
9
60
00
-7
99
9
%
40
29
Patterns of illness
 Findings
 78.4% of households had an illness in past 2 weeks
 88.3% of households had a hospitalization in past 1 yr
 21% were children
 Average Length of hospitalization was 30 days
 Malnutrition also a common cause of hospitalization
 Preferred location for treatment—
 Market drug sellers: cough, fever, diarrhea
 County hospital: TB, mental illness, dental problems
 Provincial hospital: injuries
 Usual sources: County Hosp 67%; Section doctor 28%; clinic 5%
30
Hospitalizations
Hospitalization
Digestive system
Infectious disease
Injury & poisoning
Genitourinary system
Musculoskeletal system
0
10
Top 5 conditions
%
Appendicitis
Injuries to lower extremity
Hepatitis
Malnutrition
Dyspepsia
9.5
6.2
5.8
5.4
4.1
20
30
%
40
50
31
Health in North Korea
 Half of medications were purchased on the open market
 85.5% of outpatient costs were paid out of pocket
 For hospitalizations 77% had to sell household assets, others



borrowed money
Hepatitis and malnutrition were the most expensive conditions
There were costs in addition to gifts to doctors
Length of time to usual source of care: 34 minutes
32
Payment to doctors
 90% reported “gifts” to the doctor
 Money, food, clothing, cigarettes, alcohol
 Main reason to pay is in order to secure medicines
 Payments were proportionate to length of hospital stay
 Payments were also proportionate to household income
 Women paid less for hospitalizations
 Party members paid less as well
33
% of monthly HH income paid in bribes
to the doctor to get hospital care
d
un
em
pl
oy
e
er
M
in
rm
er
Fa
er
wr
ok
ct
or
y
Fa
Of
fi
ce
w
or
ke
r
%
160
140
120
100
80
60
40
20
0
34
Satisfaction with health
care
 Satisfaction low among households
 5% were satisfied with physicians skills
 2% were satisfied with availability of medicines
 12.4% felt treatment outcomes were good
 3.9% were satisfied with cleanliness of facilities
 99.6% said water and electricity were lacking at their usual
health facility
35
Outlook
 Continued deterioration of lower tiers of the health care system
 Shortage of medications—sales of that which is donated
 Shortage of equipment
 Lack of basic utilities
 Medical and nursing staff behind in knowledge and practice
 Restriction of market sales may affect access to medications
 Population is already affected by breakdown in environmental


health
Deteriorating nutrition will contribute to increased illness
Problems for integration with ROK National Health Insurance
36