OVERVIEW OF THE SITUATION

Amidst political tensions, an estimated 10.3 million people across DPRK continue to suffer from food insecurity and undernutrition, as well as a lack of access to basic services. Recurrent natural hazards – particularly extended droughts punctuated by near-annual floods – exacerbate and create new humanitarian needs. As a result, people have crucial and unmet food, nutrition, health, water, sanitation and hygiene needs

Chronic food insecurity

Chronic food insecurity, early childhood malnutrition and nutrition insecurity are widespread in DPRK. According to the 2017 Global Hunger Index (GHI), which measures and tracks hunger worldwide, DPRK has a score of 28.2, which is classified as ‘serious’. Around 10.3 million people, or 41 per cent of the total population, are undernourished.

There are many complex, intertwined reasons for the high rates of undernutrition in DPRK. This includes mountainous terrain, with only 17 per cent of land good for cultivation, farming largely reliant on traditional farming methods, and a lack of agricultural inputs, such as quality seeds, proper fertilizer and equipment. In addition, changing weather patterns have left DPRK vulnerable to droughts and floods, which often result in reductions in agricultural production.

In addition to the Public Distribution System (PDS)1 , households increasingly rely on markets. Farmers’ markets, usually held once every 10 days, are distribution channels for a wide range of foods and necessities.

In addition to swaps and bartering, markets involve large numbers of small transactions, often made by women. Markets enable households to sell produce from their kitchen gardens or sloping lands, including vegetables, maize and potatoes, as well as some small livestock.

Most food is produced on some 3,900 cooperative farms, with 100 state farms focusing on specialized activities such as seed production, crop cultivation, poultry, fish or pig breeding. The cooperative farm sector is responsible for ensuring national self-sufficiency in the staples of maize and rice, and increasingly potatoes. Members of cooperative farms are not eligible to receive PDS rations, but have access to kitchen garden plots (approx. 97.2m2), which provide essential vegetables, maize and some livestock, helping diversify peoples’ diet. In urban areas, plots of land near apartments are cultivated by small groups while ‘sloping lands’, initially deforested and cultivated during the mid-1990s, have been organized into Users’ Groups to contribute to informal agricultural production.

In 2017, a dry spell stressed the early season crops and constrained planting and early growth of main season crops. The Government mobilised communities and resources to provide irrigation, to reduce any impact from the dry spell. Humanitarian partners also provided support to the response, including through activities to prevent and treat malnutrition, as well as life-saving health and water, sanitation and hygiene (WASH) interventions. Despite these efforts, total food production (in cereal equivalent) in 2017 was 5.45 MT, a 7.42 per cent decrease from the previous year’s 5.89 MT.

Undernutrition is countrywide

The period from the three months before pregnancy to the development of a foetus and up to the end of the second year of an infant’s life are critical for a child’s survival, and lay the basis for longer term human development. The nutritional and health status of women prior to and during pregnancy, and while breastfeeding, affects the growth and development of embryos and infants, impacting a baby’s body weight, as well as the physical and cognitive development later in life. Appropriate nutrition and health care for mother and child from conception to a child’s second birthday significantly reduces the risk of mortality and produces lifelong benefits for infants, such as healthy growth and brain development, and better educational performance. Conversely, the impact of sub-optimum nutrition during this ‘1,000 days window of opportunity’ in life is often irreversible.

Dietary quality for many people in DPRK is poor, with limited consumption of food that is rich in protein, fat and micronutrients. This results in problems related to undernourishment including physical and cognitive development concerns. The immediate causes of undernutrition (both stunting and wasting) among under-five children is directly linked to food insecurity, sub-optimum feeding practices and lack of quality health services.

According to the last National Nutrition Survey, conducted in 2012, the prevalence of chronic malnutrition (stunting) among under-five children was 27.9 per cent and the prevalence of acute malnutrition (wasting) was four per cent. These proportions can be translated into an annual caseload of 60,000 severe acute malnourished (SAM) affected children and 180,000 moderate acute malnourished (MAM) affected children who need life-saving treatment. Following a Government request, UNICEF in collaboration with the Ministry of Public Health (MoPH) scaled up the coverage of the Community Management of Acute Malnutrition (CMAM) programme in 2016-17. UNICEF field observations and Government data over this time show that with expanded coverage there has been an increase in demand for treatment of children affected by SAM.

In addition, 23.3 per cent of women of reproductive age were also malnourished. Micronutrient deficiencies, particularly in iron, zinc, vitamin A and iodine, are common. A 2014 Ministry of Public Health Report noted that 31.2 per cent of pregnant women are anaemic and the prevalence of low birth weight was five per cent. In addition to a lack of access to diverse and sufficient food, undernutrition is exacerbated by inadequate health and water, sanitation and hygiene services. Globally, it is estimated that 40-60 per cent of childhood malnutrition is attributed to poor conditions of water, sanitation and hygiene through repeated bouts of diarrhoea, worm infection and unhygienic living conditions.

Access to basic health services

Universal and free health care is guaranteed by law for all DPRK citizens. In recent years many public health gains have been achieved, including significant reductions in maternal, under-five and infant mortality rates, immunization coverage and obstetric care. Nevertheless, many parts of the country are not equipped with sufficient facilities, equipment, medicines or trained staff to provide quality health services. There are still disparities in access to services between rural and urban areas, demonstrated by under-five mortality rates 1.2 times higher in rural areas compared to urban areas.

Under-five children, pregnant women, people with communicable diseases, and people living with disabilities are the most vulnerable people in need of health services. The most common cause of maternal mortality in DPRK is post-partum haemorrhage, with women who give birth at home most at risk. According to the 2014 Socio- Economic, Demographic and Health Survey (SDHS), approximately nine per cent of all women still deliver at home, with 67 per cent of maternal deaths occurring amongst women who deliver at home.

Communicable and non-communicable diseases in DPRK remain major health concerns. Tuberculosis (TB) remains a challenge with a recent TB prevalence survey showing prevalence at 641/100,000, with significant risks in relapse and drug resistant TB cases. Although there is a declining trend in malaria, more effort is needed to improve case-based surveillance and strengthened diagnostic services to support the country meeting its elimination goal. These issues point to the need to strengthen health service delivery at the primary health care level, as well as strengthening palliative and curative cancer care.

Many health facilities in DPRK do not have the specialist equipment and trained staff to meet the specific health-related needs of people with disabilities, with only 37.4 per cent of people who require assistive devices having access to them. According to a Rehabilitation Needs Assessment conducted in 2016-17 in four provinces, diseases (communicable and non communicable) are one of the main causes of disability in DPRK (43.3 per cent). Most of secondary and tertiary care health care facilities do not have the resources or capacity to diagnose and provide acute and post-acute medical rehabilitation services, often resulting in people developing secondary complications, leading to permanent disability. Furthermore, many people with disabilities are not aware of available services.

Compounding issues related to adequate healthcare are lack of access to safe water, as well as sanitation and hygiene services. Diarrhoea and pneumonia are the two main causes of death amongst under-five children in DPRK. Diarrhoea is mainly caused by lack of safe potable water, poor sanitation and hygiene practices, and is also a contributing factor for childhood pneumonia and malnutrition. According to an assessment in 2013-2014, an estimated 11 per cent of population (2.7 million people) do not have access to piped water supply. Furthermore, 50 per cent of piped water has limited functionality due to insufficient and erratic power supply and underinvestment in maintenance. Water supply systems in most parts of the country are not fully functional, compromising the quality and quantity of water. Thus at least 13.7 million people have limited access to a safe and readily available water source. This situation and the associated health risks are compounded by the high percentage, about 23 per cent of the population, that do not have access to basic sanitation.

Natural disasters and climate change

Compounding existing vulnerabilities are the frequent disasters that hit DPRK. The IASC Index for Risk Management (INFORM) ranks DPRK 41 out of 191 countries in terms of disaster risk. Floods and drought, sometimes both in the same year, regularly strike the country. An estimated 6.2 million people have been affected by natural disasters between 2004 and 2016. Furthermore, climate change has produced, and is expected to produce further, visible impacts, with the degradation of natural resources affecting agricultural production.

Droughts have become increasingly common over the past decade, destabilizing agricultural production and food security in the long term. Prolonged dry spells often occur in the period from March to June. This is the peak time for crop planting as well as rice transplanting and therefore impact negatively on overall agricultural production. Besides the 2017 prolonged dry spell, major droughts affected DPRK most recently in 2015 and 2014.

In addition to droughts, an increase in the frequency and duration of heavy rains in recent years has contributed to recurrent floods, with major floods hitting the country every year from 2010 to 2016. In 2016, some 600,000 people were affected, and almost 70,000 people were displaced, by largescale flooding in North Hamgyong Province. These floods, combined with landslides, cause extensive damage to agricultural production, further exacerbating food insecurity and creating new humanitarian needs.

Agencies in DPRK work jointly to respond to humanitarian needs by employing an integrated approach that addresses immediate needs and seeks to reduce people’s vulnerability by focusing on community-based disaster risk management, environment protection, disaster reduction and climate change adaptation. One of the strategic objectives of humanitarian partners is to strengthen resilience to recurrent disasters, particularly floods and drought.

Impact of increasing geo-political tensions on humanitarian operations

A significant constraint on humanitarian operations is the indirect impact from the international political environment, particularly the increasing tensions in relation to the nuclear programme, and the strengthened international and bilateral sanctions. This environment has significant impacts on humanitarian agencies’ abilities to raise sufficient funds and/or implement their programmes.

In principle, the sanctions imposed on DPRK by UN Security Council Resolution 1718 (2006) and subsequent resolutions are not intended to restrict humanitarian activities or to have adverse humanitarian consequences for the civilian population. However, in practice, humanitarian activities are often significantly delayed and disrupted, notably due to the perception of risk of violating the sanctions by banks, suppliers and officials.

Since 2013, banking channels have been regularly disrupted, with agencies unable to transfer funds into the country. Prolonged disruptions have forced agencies to reprioritize implementation to only life-saving activities, as well as cancelling or postponing others. Some agencies have, or are, considering their longer-term sustainability without a consistent and stable funding channel.

Breakdowns in the supply chain for the delivery of humanitarian goods results in serious delays to operations. This breakdown is caused, in part, by the reluctance of suppliers and transport companies to procure and transport humanitarian supplies to the DPRK for fear of financial and reputational costs. There are often significant delays in procurement, as well as customs clearances, because of additional requirements for licensing and the need to ensure that equipment or supplies are not on the sanctions list. Agencies have been working hard to overcome these challenges to continue their operations.

International sanctions have also indirectly contributed to reluctance among donors to provide funds to DPRK. The overall geopolitical situation, in addition to challenges faced by humanitarian agencies has influenced donors’ attitudes and decisions on the allocation of funding. This is reflected in the radical decline in donor funding since 2012, with only 30 per cent of the requested funds in 2017 being received.

Despite these challenges, the humanitarian agencies have been making progress in meeting the needs of the most vulnerable over the years. This is the result of gradual confidence building with the Government and engagement with them on humanitarian operations. Through this approach humanitarian agencies have been able to maintain humanitarian access across the country, reaching people in need, and delivering lifesaving assistance to communities, who are largely forgotten by the international community. However, the result of limited funding has meant that agencies cannot meet the full complement of these people’s needs, resulting in sub-optimal outcomes. Without adequate resources the qualitative result that agencies are trying to achieve for those most vulnerable cannot be achieved.