Emergence and Evolution of Informal Health Care Institution in North Korea
Free health care, along with free public education, was an important pillar of North Korea’s socialism. By the Social Insurance Law of 1947, North Korea introduced free health care for workers and their family. In the post-war period, health care workers were given an important responsibility for rehabilitation of the country in the state’s efforts to rebuilding and expanding medical and child care facilities. By 1960, a complete and comprehensive free heath care system was to be established. All the steps of health care from prevention, diagnosis, medicines to hospitalization were provided for free. All residents were to receive free health care, leaving no village without doctors. Special programs were introduced for maternal care and for the protection of workers’ safety. To what extent this ideal of complete and comprehensive free health care was realized is debatable. Nevertheless, many North Korean refugees who experienced the system prior to the famine express their pride, as much as the state propagated its superiority. There are four levels to the health care system in North Korea.
[North Korea’s Health Care System]
|Level||Types of hospitals|
|Primary care||Cooperative farms- jillyosoRi-, ŭb- level – people’s hospitalsIndustrial health care office and emergency care office – primary hospitals|
|Second-level care||Gun (county) -level people’s hospitals|
|Third-level care||Do (province) -level central hospitalDo-level university hospital|
|Fourth-level care||Central hospitals, special hospitals (tuberculosis wards, etc.)|
To realize a modernized free health care system, education of health care workers was a necessity. Aid from fellow socialist states was known to be an important enabler in building the education institutions. The government invested actively in healthcare facilities and human resources. The health care workers are the actual agencies of the free and complete health care system. The state demanded and educated health care workers to make unconditional dedication for the people. The Jeongsung (dedication) movement of the 1960s made doctors to internalize this attitude towards patients and the society in general.
With the state’s inability to supply basic medicines and equipments, the free health care system virtually collapsed in its ability to provide service to the sick. Some witnesses say that the situation started deteriorating in the late 1980s. During the 1990s, the shortage of medicine and widespread deaths by starvation incapacitated health care workers. With the virtual collapse of the free socialist health care system, a number of coping strategies emerged and gradually formed informal institutions. If the former demands a complete dedication from the health care workers, the latter operates based on trust, expertise, reward and profit.
Ordinary people resorted to three alternative means. (1) People went to jangmadang (informal marketplace) to buy medicines. Medicines in jangmadangs were imported by small traders from China. Domestically-produced medicines flowed into jangmadangs by pilfering of medicines by related personnel somewhere along the medical supply channel. During the period of the famine (1995-1997), the price of essential medicines (e.g. Levomycetin for typhoid) was high enough to plunge many starving households into death, causing many to flee across the river. (2) People sought the help of traditional specialists. Unregistered healing practices had been widespread but were banned by the state. Their popularity among residents reappeared in the 1990s as the state health care system ceased to function. But private house practices emerged in the post-famine period are also operated by doctors in the hospitals. (3) A resort to herbal plants and traditional remedies is a common and desperate attempt to those who have physical and financial barriers to accessing either formal or informal health care personnel.
Private supply of medicines
During the non-ration period, malnutrition made people susceptible to epidemics. Typhoid and cholera epidemics took the lives of many who had already been weakened by a prolonged period of malnutrition. Supplies of medicines to the hospitals were cut short. Pharmaceutical factories were no longer capable of producing necessary medicines. Somewhere along the line of supply from the center to levels of hospitals, medicines were flown into jangmadangs. Traders also brought in medicines from Chinese merchants to jangmadangs. The cost of medicines in jangmadangs during the earlier period was exorbitantly high. Families of a sick child had to give up on the invalid to prolong the life of other children. Or to save the child’s life, all the household furniture had to be sold in order to buy a few pills of medicines. This meant a significant change in their family’s path of struggle against starvation. It became a turning point for the families or members of the families to make decision to cross the river to China. This means, in most cases, the separation of family members.
Because there are many deleterious counterfeit medicines from China, patients buy medicines from jangmadang and bring them to jillyoso (primary health care office) and hospital doctors to confirm that what they bought are safe to take. In addition, with poor nutritional status, western medicines often do as much harm as good. Further reliance on herbal plants and oriental medicines has occurred, and the state has also promoted oriental medicine over western medicine. There are now intermediary dealers who supply oriental and western medicines to sellers in jangmadang and private households. The use of oriental medicines became widespread and is promoted by the state. Because of the need of the expertise and credibility in selling medicines, retired doctors have become medicine sellers in the marketplace. They operate in network with hospital doctors; doctors tell their patients to buy medicines from certain sellers with whom the doctors have previously-established relationship.
Private payment to hospital doctors
Gift-giving had been a common practice in North Korea. But informal payment to doctors during the famine period was not a common practice. Given the dire condition of all, doctors could not demand payment from patients. Gradually payment culture seems to have emerged. A number of preexisting cultures may have played a role. (1) Gift of appreciation was a common practice even before the famine. (2) Visiting hospital doctors’ home was a common practice. (3) Self-declared folk medicine specialists had operated at home.
During the non-ration period, bringing gifts to doctors was common but not normalized. Doctors during this period could not make living out of working in the hospitals. They had to go out to the streets and farms and conduct market activities like any other ordinary North Koreans. To maintain hospitals functioning by giving incentives for health care workers to stay at their workplace, the state authority on ad hoc basis gave areas of land for health care workers to cultivate and survive on their own.
Gradually an informal payment to doctors emerged. Resettlers who stayed in North Korea till recent years testify that private payment was almost always necessary in some forms. After all, a hospital became a place to get diagnosis. When Sunhee (pseudo name) had a toothache, she visited jillyoso to see if her tooth had to be taken out. She then went to the doctor’s house in the evening to get her tooth taken out. A patient senses that she should come to the doctor’s house to receive the treatment and that she also has to bring a pack of high quality cigarette, a bundle of noodle or a small sack of corns. A more recently arrived refugee from a border region says it has become a norm to bring thirty or forty thousand won (NK) as a show of appreciation to doctors. Because of this norm, she argues that doctors in the hospitals do not necessarily have to see patients at home to earn extra income to make living.
“Private house doctors”
A noticeable phenomenon in the post-famine period is that doctors have begun to operate in their private house, and they are popular to residents. During the famine period, people sought the help of these individuals knowing that they could not access treatment from the hospitals without money and personal relationships. Under such circumstances, it became more convenient for patients to seek private house doctors than to visit hospitals. However, patients seek private house doctors not just out of convenience but also because of issues of trust. Private practices are more trustworthy than of doctors at the hospital who do not have as much incentive as private doctors to establish a good reputation and trust relationship with patients. In the earlier period, there were many medical accidents caused by scam doctors who provided false medicines and treatments. Though cover up methods could be employed, these practices cannot be sustained for long.
Private practices provide resources, expertise, and convenience (accessibility) the state health care system cannot provide. Patients provide trust, reputation and demands. In a small town in Southern Hamkyong Province, a jillyoso doctor receives patients at home after working hours. Because she is effective and is thus well-respected, many residents prefer to see her. Since selling medicines at home is prohibited, she refers her patients to another private house which sells medicines. This indicates that private house doctors and private house pharmacies have mutually beneficial relationships and operate in a network. She also has a mutually beneficial relationship with a police officer who looks after her. The doctor was once dismissed from jillyoso and was ordered to “revolutionize herself (being sent to a cooperative farm for labor for three years)” for this illicit medical practice. Regardless, she continued to see patients and patients continued to seek her care. Not only so, patients no longer went to the jillyoso where they could not find her. Jillyoso lost its face and after all had to readmit the doctor. An interviewee from North Hamgyong Province informed me that many retired doctors (the retirement age is 56 for women and 60 for men) saw patients at home and people also preferred to see them than to see new doctors at jillyosos and hospitals. There was a widespread sentiment among residents in her town that young doctors who were trained after the non-ration period were not as eligible as old doctors who had proper education and experience of seeing many patients.
Free healthcare and free education were the two pillars of the North Korean socialist system. The virtual collapse of free health care in North Korea means the end of socialism in North Korea. Yet, the state has failed to regulate what would be considered anti-socialist practices of health care workers. When I asked my interviewees why such “anti-socialist practices” cannot be regulated, two interviewees responded hurriedly with anger. One response was: “the residents’ disaffection (panbal) is too high.” The term can be interpreted in terms of different degrees of disaffection, from residents’ actual expression of complaints to such regulation being widely unpopular. Another response is: “they are doing what the state cannot provide. So why would you regulate such practices?” Residents and officials share the tacit agreement that the state, as it proclaims, should provide health care. When it cannot, it also loses the authority to regulate anti-socialist activities which nevertheless satisfy the basic needs of the residents and quell widespread disaffection of the residents on the authority.
Another common response is that normally these private practices operate with the help of the local police who accepts bribery from the practices. More importantly, the local police officers also need the doctor’s service and expertise for his family’s survival and wellbeing. Local jillyosos and hospitals also need these doctors’ official association with them so that they continue to be respected by the patients.
The dynamics seem particularly evident at the primary care level, and to what extent upper level institutions are “privatized” demands further exploration. The dynamics of these informal grassroots health care institutions are relevant to external actors’ aid policies as well as to North Korea’s health care reform in the future. If the formal health care system does not gain trust from the patients, patients would resort to private practices and these private practices would continue to thrive.
Selected References and Links
Amnesty International, The Crumbling State of Health Care in North Korea, 2010. http://www.amnesty.org/en/library/info/ASA24/001/2010
Good Friends. North Korea Today. http://www.goodfriends.or.kr/n_korea/n_korea1.html (in Korean), http://goodfriendsusa.blogspot.kr/ (in English).
Hwang, Sang-ik. “North Korea’s Health Care System.” Found at www.nkhealth.net (in Korean)
Joo, Sungha’s Blog http://blog.donga.com/nambukstory/ (in Korean)
Yi, Sŏng-bong. Pukhan pogŏnŭiryoch’egyeŭi hyŏngsŏnggwajŏnggwa t’ŭkching, [The emergence of North Korean healthcare system and characteristics]. Tongilmunjeyŏngu, Vol.52 (2009).