National Health Priorities under the Kim Jong Un regime in Democratic People’s Republic of Korea (DPRK), 2012–2018

Abstract

The National Health Priorities (NHP) 2016–2020 is the healthcare policy which was most recently announced to the international community by the Democratic People’s Republic of Korea (DPRK). However, understanding DPRK’s internal and practical perspectives and priorities in the healthcare sector is difficult. Hence, there is a need to analyse domestic documents. One such document is the Sa-seol—a kind of editorial in the first issue of the each quarterly medical journal published in DPRK. We analyse the content of 56 Sa-seol published in eight medical journals during the Kim Jong Un regime (2012–2018), and then classified them in terms of their relevance to each of 12 items presented in NHP 2016–2020. Sa-seol mentioned a total of 612 medical and health issues which could be classified into 12 items based on NHP 2016–2020. We divided the items into three categories of concern in the NHP by summarising the total number of mentions: the areas of the most, medium and least concern. The areas of most concern (development of medical science and technology) are not directly related to the present improvement of health and rather, seem to focus on more future development. The areas of medium concern focused on disease control, health systems and social determinants of health. The areas of the least concern were emergency or disaster response and reproductive health services. This study suggests a two-track approach for healthcare cooperation with DPRK:, a well-balanced approach between ‘present’ and ‘future’ needs.

Correspondence to Dr Woo Taek Jeon; [email protected]

Summary box

• To date, there have been no studies on the Sa-seol in the medical journals published (government-written editorials) in the Democratic People’s Republic of Korea (DPRK).

• We analyse the content of 56 Sa-seol published during the Kim Jong Un regime (2012–2018), and then classified them (into areas of most, medium and least concern) based on their relevance to each of the 12 items presented in the National Health Priorities (NHP) 2016–2020.

• The area of most concern has two items, including the development of medical science and technology, especially in DPRK’s traditional complementary medicine called ‘Koryo Medicine’.

• The area of medium concern has eight items, including disease control, maternal and child health, health system and social determinants for health.

• The area of least concern has two items, including response to emergencies and disasters and reproductive health services.

• Future cooperation of the international community with the DPRK healthcare sector needs to consider a balance between relief support and the development of medical technology.

Introduction

The Democratic People’s Republic of Korea (DPRK) is one of the world's most closed countries. Accordingly, it is difficult to obtain accurate statistics on healthcare in DPRK, and even the internationally reported data do not inspire sufficient confidence in its accuracy and reliability.^1–3 Indeed, it is not known what healthcare policy is actually in place in DPRK, and this is a cause of confusion when the international community discusses the healthcare sector with DPRK.

There are three main ways to understand the national healthcare policy in DPRK. The first is the healthcare policy that has traditionally been proclaimed by DPRK. It is based on the three components of free medical service, preventive medicine and section doctor system (a system in which one doctor is responsible for the primary care of around 130 households).^{4 5} However, due to the persisting economic difficulties, the healthcare policy that DPRK promoted as the pride of the socialist system has not functioned properly since mid 1990s.

The second is the healthcare policy that the government, especially the Ministry of Public Health (MoPH), jointly produces and announces with international organisations such as the WHO, United Nations Children’s Fund and United Nations Fund for Population Activities. It can be confirmed mainly through three official reports : the National Health Priorities (NHP),¹ (table 1) ^6–8 Country Cooperation Strategy (CCS),² and Medium Term Strategic Plan for Development of Health Sector DPRK (MTSP).³ All these are organically linked with each other through closed discussions with DPRK authorities and WHO DPRK representatives in the process of preparation.^9–124 They represent that DPRK is making efforts to establish and implement healthcare policy in line with international standards. At the same time, however, there is a possibility that DPRK, which places great emphasis on national reputation and face, has possibly written these documents to demonstrate their national policies to the international community without enough intention to implement them. In fact, it is difficult to confirm whether the government is implementing healthcare activities in accordance with such internationally proclaimed national health policy.

Table 1

Changes on the NHP of DPRK

Area	NHP 2004-2008	NHP 2010–2015	NHP 2016–2020
1	Tuberculosis, malaria, HIV/AIDS	Decrease burden of communicable diseases.	To intensify the development of the Juche-oriented medical science and technology.
2	Other infectious diseases (hepatitis B, intestinal infectious diseases and parasitosis)	Delivery of quality medical services.	To establish nation-wide telemedicine system and improve the operational quality.
3	Non-communicable diseases (CVD, cancer, oral disease)	Strengthen household doctor system.	To upgrade the health sector to information oriented one.
4	Tobacco control	Protect and promote maternal, child and elderly health.	To strengthen systems for prevention and surveillance of diseases.
5	Maternal and child health, including immunisation	Strengthen prevention and control of major NCD and risk factors.	To facilitate the modernisation of medicine manufacture, production of Koryo traditional medicine and modernisation of medical tools, production.
6	Food safety	Provide sufficient medicines (essential medicines and OTC medicines).	To provide safe and healthy environment.
7	Nutrition	Strengthen human resources for health.	To strengthen section doctor system and improve the quality of health service.
8	Mental health	Integrated health management information system.	To improve the technical competency of health workers.
9	Blood safety	Strengthen emergency preparedness.	To improve the maternal, child and aged healthcare.
10	Health and environment	Intensify international cooperation and partnership.	To strengthen professional development of midwives for providing quality SRH services.
11	Developing and application of new technology		To strengthen the capacity of leadership and management in public health.
12	Essential drugs and drug quality assurance		To develop the capacity for immediate response to emergencies and disasters.
13	Strengthening of health system
14	Training/reorientation of health workers

CVD, cardiovascular disease; DPRK, Democratic People’s Republic of Korea; NCD, Noncommunicable Diseases; NHP, National Health Priorities; OTC, Over-the-Counter; SRH, Sexual and Reproductive Health.

The third is the healthcare policy instructed by the DPRK authorities to its own community-based healthcare workers which, may reflect the most practical and realistic health policy that the DPRK government seeks to implement. Such instruction may be given in a variety of ways, and one of them is through the ‘Sa-seol’ (editorial) in the first issue of every quarterly medical journal published in DPRK. The Sa-seol tends to have a propaganda slogan as a title, and, as is the case of editorials, no specific author name. It is a directive message from the DPRK authorities which mainly contains an analysis of the healthcare contents of Kim Jong Un’s annual New Year’s address.¹³⁵ Hence, the Sa-seol,⁶ as a vivid resource, need to be analyzed to compare the practical direction and implementation of health care policies with the internationally proclaimed health policy in DPRK.

In this context, this paper has the following objectives. First, it aims to analyse how frequently the 12 items in NHP 2016–2020 are mentioned in the Sa-seol in order to identify DPRK’s domestic priorities. Second, it aims to find how the most mentioned NHP items are described and explained in the Sa-seol. Third, it aims to suggest some issues to be considered by the international community in future healthcare cooperation with DPRK.

In DPRK, there are nine medical journals⁷ which publishes original articles. Most of these are published four times a year. Among them, issues of the eight journals published between 2012 (Kim Jong Un’s official regime began in 2012) and 2018 could be obtained and copied from the Information Center on North Korea at the National Library of Korea. However, the Journal of Koryo Medicine is only possibly obtained for 3 years issued, between 2016 and 2018, so it is excluded from the analysis. Analysing how the items of NHP presented as the national plan are handled in the Sa-seol to examine the direction of DPRK’s healthcare plan indirectly under the circumstances of insufficient information on the status of healthcare in DPRK. Thus, a total of 56 Sa-seol from eight medical journals within 7 years between 2012 and 2018 were collected and analysed sentence by sentence and then classified in terms of their relevance to each of 12 items presented in NHP 2016–2020 (figure 1). We calculated the percentage of mention of each item out of the total number of mentions and then rearranged the order of items by the frequency of mentions.

Figure 1. Composition of Sa-seol in medical journal of Democratic People’s Republic of Korea and its brief explanation.

Categories of concern

The 12 items in NHP 2016–2020 were classified into three categories: the most, mentioned categories of concern (table 2). Notably, the way the two most mentioned items are explained in the Sa-seol are as follows:

Table 2

The number of frequency in the Sa-seol, in the eight medical journals published during the Kim Jong Un regime (2012–2018), relevant to each of 12 items presented in NHP 2016–2020

Frequency ranking	Items on the year NHP 2016–2020	2012	2013	2014	2015	2016	2017	2018	Total number of frequency	Percentage (%)	Category of concern
1	To facilitate the modernisation of medicine manufacture, medical tools, and production	9	12	14	14	10	13	25	97	27.1	Most
	To facilitate the production of Koryo traditional medicine	11	11	11	8	12	7	9	69
2	To intensify the development of Juche-oriented medical science and technology	21	21	19	18	24	17	15	135	22.1
3	To strengthen systems for the prevention and monitoring of diseases	3	4	4	13	8	6	15	53	8.7	Medium
4	To upgrade the health sector into an information-oriented one	5	7	8	4	10	7	8	49	8.0
5	To improve the technical competency of health workers	6	7	8	7	7	7	5	47	7.7
6	To establish a nationwide telemedicine system and improve operational quality	4	7	10	6	4	4	6	41	6.7
7	To strengthen the capacity of leadership and management in public health	1	3	5	6	10	5	10	40	6.5
8	To improve maternal, child, and aged healthcare	7	7	3	2	4	3	5	31	5.1
9	To strengthen the section doctor system and improve the quality of health service	3	2	3	2	5	4	7	26	4.2
10	To provide a safe and healthy environment	3	3	3	1	6	2	4	22	3.6
11	To develop the capacity for immediate response to emergencies and disasters	0	0	0	0	0	1	0	1	0.2	Least
12	To strengthen the professional development of midwives for providing quality sexual and reproductive health services	0	0	0	0	0	0	1	1	0.2
Total		73	84	88	81	100	76	110	612	100

NHP, National Health Priorities.

(1) Production of pharmaceuticals and combination of the new medicine (western medicine) and Koryo medicine (traditional Korean medicine): As part of DPRK’s efforts to supplement the healthcare delivery system and to modernise the quality of medical care, it has increasingly emphasised the supply of medicines and the improvement of technology for combining Koryo medicine.¹⁴⁸ The high consumption of Koryo medicine is also reported in WHO as the essential drug policy of DPRK.¹⁵ Koryo medicine, which poses less financial burden to use and is easily accepted by the people, has been strongly emphasised as the unique medical system of DPRK to be utilised in combination with western medicine. According to the Sa-seol, the combination of Koryo medicine and western medicine was related to (1) the interest in developing new drug productions with herbal ingredients^{16 17}; (2) the emphasis on preventive treatment through natural treatment methods, such as bathing in hot springs, mineral water and mud^{18 19}; and (3) the interest in health supplement food and the operation of medical facilities which are based on Koryo medicine.¹⁷ These seem to have come from DPRK’s attempt to solve the country’s medical problems by themselves and to increase the production of medicines in response to the difficulties in importing medicines and medical supplies amid strengthened sanctions.^20–23

(2) Independent development of medical science and technology and the reinforcement of healthcare workers: DPRK is striving to make substantial efforts to strengthen science and technology. DPRK urges the development of science and technology as the path to economic progress.^{24 25} In particular, the repeated expression ‘the development of our style of medical science and technology’ is closely related to the policy of ‘emphasis on scientific technology’ which would enable a leap into an economic power through the strengthening of the technical capacity of workers and the development of science and technology autonomously based on DPRK’s resource utilisation.^26–29 In addition, the number of published articles in Science Citation Index (SCI) journals and the actual opportunities to hold international academic conferences, including joint research with foreign researchers, have been steadily increasing.^{22 30 31} Further, active educational support for the younger generations is provided, including the opportunity to obtain a doctorate degree (PhD) in their 30s, far younger than the case in the past based on the previous DPRK’s standards.^32–36

More future development than current troubleshooting

The healthcare sector needs to be developed step by step from primary care to more advanced technologies. However, our analysis suggests that DPRK is willing to leap forward through intensive investment and development of medical and scientific technologies even though the health system of DPRK still faces many challenges, and need more humanitarian work.³⁷ DPRK’s attention is more focused on ‘future development’ than ‘current troubleshooting’. Such a policy may have a positive aspect, in that it prepares for the future in the long term. However, these principles may not be appropriate in healthcare. It may be necessary to promote tertiary care and the development of advanced medical technology after stabilising efforts to protect the lives and health of the people through basic primary and secondary healthcare. Therefore, a well-balanced approach between ‘present’ and ‘future’ is needed in the priority of DPRK’s healthcare policy, for building a strong and sustainable healthcare system in DPRK.

This analysis has a couple of limitations. First, Sa-seol is not an official healthcare policy document. It is a propaganda document published in medical journals and so, there are limitations to using it only as a basis for understanding DPRK’s national healthcare policy. However, Sa-seol contains detailed information in each specialty area sufficient to grasp the macro-direction of DPRK healthcare policy in a situation where official documents on DPRK healthcare policy are hard to obtain. Second, this study used frequency analysis to identify priorities in the national healthcare policy. However, the background and reason for such comments in the Se-seol were not analysed. This shall be the subject of further research.

Conclusion

Healthcare policy is one of the most fundamental and important policies in a country, especially for addressing the health needs of vulnerable groups such as the poor, aged, women and children. So, understanding the priority of national health policy is essential in international cooperation. This study suggests a two-track approach for healthcare cooperation with DPRK in the future. It is necessary to progress international cooperation for the development of medical and scientific technology, regarded as a priority issue by DPRK, and at the same time, to strengthen the primary healthcare system through the provision of sufficient supplies, human resource education and empowerment, and establishment of essential healthcare infrastructures. Furthermore, sufficient dialogue is required in the process of international cooperation to ensure that the international community and DPRK understand each other's thoughts and positions.

Footnote

The NHP has been published three times: 2004 (NHP 2004–2008), 2009 (NHP 2010–2015), and 2016 (NHP 2016–2020). However, the original documents of DPRK’s NHP cannot possibly be obtained due to restrictions on access to DPRK’s domestic data. But it is included in the MTSP and CCS report as the part of a chapter.

The CCS suggests the Strategic Agenda aimed at making the greatest contribution to global health, including strengthening the technical, intellectual, ethical, and political leadership of all the member states in the international health sector. The report has been published threetimes: 2004 (CCS 2004–2008), 2009 (CCS 2009–2013), and 2014 (CCS 2014–2019).

The MTSP suggests the Strategic Goals for providing the framework in the coordination of development investment based on investigation of the health needs of DPRK through strategic investment area designation, national monitoring and evaluation systems, and financial gaps for priority interventions. The report has been published two times: 2009 (MTSP 2010–2015; MTSP 1) and 2016 (MTSP2016–2020; MTSP 2).

According to the MTSP and CCS, WHO and many international organizations which have representative offices and/or have officials in DPRK, and support the MoPH of DPRK in developing the health care mid-term plan.

In DPRK, New Year’s address is a very important document, which reveals the specific tasks and practices in each social sector within a year. When a New Year’s address is announced, each sector of the national policy begins to re-organize its contents related to there spective specialty area and submits the specific plan based on the address.

Sa-seol in the medical journals contains such customized and detailed contents as the instruction to health care workers about the authority’s directional goal during the year. It consists of two parts: the achievements in the health care sector of the last year and the future instructions to be achieved for the current year, conveyed in a strong, concise manner.

There are nine medical journals such as Chosun Medicine, Preventive Medicine, Basic Medicine, Korean Pharmacy, Dentistry, Otolaryngology, Ophthalmology, Internal Medicine, Orthopediiics, Pediatric Obstetrics & Gynecology Clinic, and Koryo Medicine. These journals are published by the Medical and Scientific Publisher in DPRK.

Koryo medicine is DPRK’s traditional medicine based on acupuncture and botanical drugs, principally similar to South Korea’s “Hanmedicine”. Since the founding of the country, DPRK has consistently emphasized and promoted the development of Koryo medicine and urged the policy to combine it with Western medicine through Article 7 and 31 of the Medical Law and Article 16 and Chapter 4 of the People’s health Law.

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