Health Care in North Health Care in North KoreaKorea

Tiers of the systemsTiers 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, National Maternity Hospital, ~equivalent in each province~equivalent in each province

County HospitalCounty Hospital

County HospitalCounty Hospital

Nutrition rehabilitation wardNutrition rehabilitation ward

County HospitalCounty Hospital

Nutrition rehabilitation wardNutrition rehabilitation wardTuberculosis hospitalTuberculosis hospital

Felt by many to be serious under reporting

County HospitalCounty Hospital

13

Pyongyang Medical University

Key indicators DPRK ROK

Life Expectancy (birth) 67y (71 in 1990) 79yInfant Mortality Rate/10,000 42* 5Under 5 Mortality Rate/10,000 55* 5Maternal Mortality RatioLife time risk of death in pregnancyWorld ranking

3701:140

57

221:3700

167

Stunting children U5 45% -Doctors/10,000 33 16Nurses/10,000 41 19Hospital beds/10,000 132 86Populations >60 yrs 9.6% 11.1%

*unchanged since 1990

Health conditionsHealth 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 conditionsHealth 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

Other 32%

Malaria 5%Measles 5%

Diarrhea 17%

Acute respiratory infections (ARI) 19%

Peri-natal18%

Malnutrition a factor in 54% of <5 deaths

Worldwide

Health conditionsHealth 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

Other 32%

Malaria 5%Measles 5%

Diarrhea 17%

Acute respiratory infections (ARI) 19%

Peri-natal18%

Malnutrition a factor in 54% of <5 deaths

55% mothers underweight;35-61% anemic(UNICEF)

Worldwide

Traditional medicinesTraditional 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

H1N1H1N1

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

HospitalsHospitals

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 filmwide use of fluoroscopy Continuing deterioration of equipment Water and sanitation provisions are poor Electricity supply is intermittent

Health workersHealth 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 workersHealth 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 structureHealth 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 HospitalChronic shortage of medicines

26

Health systems researchHealth 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 FindingsDemographic 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 FindingsDemographic 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 Monthly Household income income (2004 NK won)(2004 NK won)

US$43

30

Patterns of illnessPatterns 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 childrenAverage Length of hospitalization was 30 daysMalnutrition 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

Hospitalization

%

0 10 20 30 40 50

Musculoskeletal system

Genitourinary system

Injury & poisoning

Infectious disease

Digestive system

Acute illness episode

%

0 10 20 30 40 50

Injury & poisoning

Digestive system

Symptoms & signs

Respiratory system

Infectious disease

Top 5 conditions %

Diarrhea & gastroenteritisCommon coldFever of unknown originDyspepsiaInfluenza

39.327.612.111.2

1.9

Top 5 conditions %

AppendicitisInjuries to lower extremityHepatitisMalnutritionDyspepsia

9.56.25.85.44.1

HospitalizationsHospitalizations

32

Health in North KoreaHealth 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 doctorsPayment 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 % of monthly HH income paid in bribes to the doctor to get hospital careto the doctor to get hospital care

35

Satisfaction with health Satisfaction with health carecare

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

OutlookOutlook

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