Author: Eun Jeong Soh, ANU

Health care has been a successful area of international cooperation for North Korea. Yet, there has been little discussion of daily health care practices, which remain largely hidden outside of the formal health care system. How much is known, for instance, about what people in North Korea do when their children fall ill?

According to the World Health Organization’s (WHO) Country Cooperation Strategy: DPRK, published in 2009, chronic malnutrition and growth stunting in children under the age of five continues at a concerning rate. Due to the consequent susceptibility to communicable and non-communicable diseases, the demand for medical services is high. Yet, the degradation of health infrastructure, lack of transportation services and unreliable electricity and water supplies are all obstacles to accessing health care in North Korea.

At the same time, North Korea has had a lower child mortality rate, higher immunisation and maternal care access rates, and a higher number of health workers (300,000) than many Southeast Asian countries, according to official data acquired by WHO. But while North Korea maintains large health institutions and perhaps too many health workers, basic resources are lacking.

In contrast to a number of incremental changes toward marketisation — which the government inevitably adopted — Pyongyang has emphasised its intention to maintain completely free and socialised health and education sectors. As a result, despite lacking the resources to provide for the country’s over 700 hospitals and over 6000 clinics, privatisation and decentralisation in the health care sector has been minimal. There have been reports of privately owned and financed pharmacies in the streets of major cities and in a number of hospitals. Nevertheless, health workers are generally reluctant to seek outside resources directly and autonomously for fear of getting into trouble.

Under this peculiar context, informal health care practices — such as informal payments, a black market for medicines and home-practicing doctors — have developed. In a study conducted by the United States Institute of Peace, 90 per cent of respondents admitted to having made informal payments to doctors and that purchasing medications on the black market was common. Interviews with defectors resettling in Seoul confirm this trend. People have learned to treat themselves at home using antibiotics, glass syringes bought from the black market and herbal or traditional medicines. Doctors and pharmacists have created informal referral networks based on a sense of mutual trust in each other’s expertise and competence.

Another noticeable phenomenon is the emergence of home-practicing doctors. Patients have come to prefer private house doctors — out of both convenience and trust — over hospitals where one has to bring everything from medicines to meals. Such practices are illegal but not uncommon. Even in the old days, given the close doctor-patient relationship fostered by the North Korean-style free health care system, people in emergency situations visited doctors’ homes.

How health workers and patients have coped with the decline of hospitals, and the strategies and relationships that have emerged, is based on norms and practices that were fostered by the ethos of North Korea’s free socialist health care system: to engage closely with and dedicate oneself to patients.

But informal health care practices in North Korea show both aspects of the emergence of capitalism as well as the continuation of pre-existing norms and habits.

While the WHO Action Plan — designed to tackle and reduce health care burdens — is essential, aid providers should consider the prevalence of informal health practices that have developed under the declining capacity of the country’s formal health care system.

One strategy that they might consider would be to cooperate more closely with individual hospitals in a sustainable manner, assisting them to be self-reliant by donating appropriate scales of medicine, equipment and infrastructure.

Health care provides a constructive avenue for the international community to engage with North Korea. But, external aid agencies could make their aid more effective and relevant through innovative strategies that give greater consideration to the informal nature of the vast majority of health care practices in the country.

Eun Jeong Soh is a post-doctoral fellow at the ANU College of Asia and the Pacific. Her research interests include health management and market and trade activities in North Korea.