Health Care in North Korea

1. Health Care in North Korea

2. 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

3. National Maternity Hospital, ~equivalent in each province

4. County Hospital

5. Nutrition rehabilitation ward County Hospital

6. Tuberculosis hospital Nutrition rehabilitation ward Felt by many to be serious under reporting County Hospital

8. County Hospital

13. Pyongyang Medical University

16. *unchanged since 1990

17. 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

18. 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%

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 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%

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

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/food sales • 64% of houses were less than 30m2 in size (18 ft x 18 ft)

28. 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)

29. Monthly Household income (2004 NK won) US$43

30. 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%

31. Hospitalizations

32. 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

33. 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

34. % of monthly HH income paid in bribes to the doctor to get hospital care

35. 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

36. 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