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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

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Tiers of the systems
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





Tuberculosis hospital

Nutrition rehabilitation ward

Felt by many to be serious under reporting

County Hospital





Health conditions
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 conditions1
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 reports of death from starvation from much of DPRK

  • 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

Worldwide

Malaria 5%

Measles 5%

Other 32%

Diarrhea 17%

Malnutrition a

factor in 54%

of <5 deaths

Peri-natal

18%

Acute respiratory infections (ARI) 19%


Health conditions2
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 substantially

  • Continuing reports of death from starvation from much of DPRK

  • 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

Worldwide

Malaria 5%

Measles 5%

Other 32%

Diarrhea 17%

Malnutrition a

factor in 54%

of <5 deaths

55% mothers underweight;

35-61% anemic

(UNICEF)

Peri-natal

18%

Acute respiratory infections (ARI) 19%


Traditional medicines
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

  • 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
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 workers1
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

  • 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

  • Provincial hospital (9 provinces)

County Hospital

Chronic shortage of medicines


Health systems research
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


Demographic findings
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)


Demographic findings1
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)


Monthly household income 2004 nk won
Monthly Household income (2004 NK won)

US$43


Patterns of illness
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%



Health in north korea
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


Payment to doctors
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



Satisfaction with health care
Satisfaction with health care hospital 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


Outlook
Outlook hospital care

  • 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


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