Archive for the ‘Pediatrics’ Category

DPRK health care data quality audit

Wednesday, December 1st, 2004

The GAVI Alliance (formerly known as the Global Alliance for Vaccines and Immunisation) is a public-private partnership focused on increasing children’s access to vaccines in poor countries. Partners include the GAVI Fund, national governments, UNICEF, WHO, The World Bank, the Bill & Melinda Gates Foundation, the vaccine industry, public health institutions and nongovernmental organizations (NGOs). The GAVI Fund provides resources for the Alliance programs. The Alliance provides a forum for partners to agree upon mutual goals, share strategies, and coordinate efforts.

In 2004, The GAVI Alliance commissioned a data quality audit of the North Korean immunisation system to facilitate future collaboration.  The audit was designed to assist countries receiving support to improve their information systems, and aid with accuracy in reporting.

The report is saved to this website here:DQA_2004_KoreaDPR.pdf
On the web, it is located here.

The results of the audit are not surprising given the centrally-planned nature of the North Korean health bureaucracies combined with their penchant for secrecy.  I recommend reading the full report to get an idea of how efficient of how socialist institutions are with data, but here are some points I considered interesting:

-District immunization information is not passed on to the national level, but combined at the county level.

-Out of 206 counties, 168 were audited.  The rest were excluded for “security reasons”.

-The Ministry of population and Health contains a National Hygeing Control Committee, which controls the National Hygeine and Anti-Epidemic Institute which is responsible for the Expanded Programme on Immunization.  This program was supported by UNICEF and the WHO.

-Officially, immunizations are offered in all 206 counties to children under one year old.  Records are suposed to be made on an individual’s Child Health Card, and in the doctor’s own ledgers.  These health cards are stored at local health facilities and are supposed to move with the child.  Immunizations are distributed by the national government and are carried out one day per month.

-Outside of the national level, where one computer was used to for entering data, no computers were seen (all done by hand).

-In cases of county data, many errors were detected in the addition of monthly subtotals which could not be explained by the district staff.  The auditors concluded that the district used the 2003 figures rather than admit to missing 2002 data to meet the criteria of the audit.

-County managers do not take the previous year’s achievements into account in order to set realistic targets for the next year.

-Supervision of immunization activities was weak.  Only two counties could provide a written schedule of supervision.

-One health unit destroyed its records.

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Through a glass, darkly

Thursday, March 11th, 2004

The Economist
3/11/2004

So far as a visitor can tell in this secretive land, North Korea’s economic reforms are starting to bite. But real progress will require better relations with the outside

COMMUNIST North Korea has started to experiment with economic reform, and opened its door a crack to the outside world. Though its culture of secrecy and suspicion stubbornly persists, it was deemed acceptable for your correspondent to visit Pyongyang’s Tongil market last week. Here, stalls are bursting with plump vegetables and groaning with stacks of fresh meat. You can even buy imported pineapples and bananas from enthusiastic private traders.

But how about a photograph? Most foreigners think of North Korea as a famished nation, and the authorities are evidently keen these days to tell the world about the great strides their economy has made since reforms were introduced in July 2002. Logic might seem to suggest that a snap showing the palpable result of the reforms would be acceptable too. But it is not. The officials were friendly but firm: no pictures of fat carrots.

The July 2002 reforms were ground-breaking for North Korea: the first real step away from central planning since the dawn of communism there in 1945. The government announced that subsidies to state-owned enterprises were to be withdrawn, workers would be paid according to how much they produced, farmers’ markets, hitherto tolerated, would become legal and state enterprises would be allowed to sell manufactured products in markets. Most of these enterprises, unless they produced “strategic items”, were to get real autonomy from state control.

Almost two years on, how to assess the success or failure of these reforms? That climate of secrecy makes it deeply frustrating. Even the simplest of statistics is unavailable. Li Gi Song, a senior economist at Pyongyang’s Academy of Sciences, says he does not know the rate of inflation. Or maybe he is not telling. After all, he says, “We can’t publish all the figures because we don’t want to appear bare before the United States. If we are bare then they will attack us, like Afghanistan or Iraq.” So what follows can be little more than a series of impressions.

The indications are that the reforms are having a big impact. For a start, North Korea has recently acquired its first advertisement (pictured above)—for foreign cars, assembled locally by a South Korean majority-owned company. Or, to be more basic, take the price of rice, North Korea’s staple. Before the reforms, the state bought rice from state farms and co-operatives at 82 chon per kilo (100 chon make one won, worth less than a cent at the official exchange rate). It then resold it to the public through the country’s rationing system at eight chon. Now, explains Mr Li, the state buys at 42 won and resells at 46 won.

North Korea’s rationing system is called the Public Distribution System (PDS). Every month people are entitled to buy a certain amount of rice or other available staples at the protected price. Thus most North Koreans get 300g (9oz) of rice a day, at 46 won a kilo. According to the UN’s World Food Programme (WFP), that is not nearly enough. Anything extra has to be bought in the market.

In theory, even in the market the price of staples is limited. Last week, the maximum permitted rice price was marked on a board at the entrance to Tongil as 240 won per kilo. In fact, it was selling for 250. WFP officials say that in January it was selling for 145 won, which points to significant inflation, for rice at least. This is not necessarily a bad thing, since it means that the price is coming into line with the market.

The won’s international value is also adjusting. Since December 2002, the euro has been North Korea’s official currency for all foreign transactions. In North Korean banks, one euro buys 171 won. In fact, this rate is purely nominal. A semi-official rate now exists and the price of imports in shops is calculated using this.

Last October, according to foreign diplomats, a euro bought 1,030 won at the semi-official rate. Last week it was 1,400. A black market also exists, in which the euro is reported to be fetching 1,600 won—which implies that the won is approaching its market level. It also means, however, that imported goods have seen a big price-hike. For domestically-produced goods, like rice, prices may well go on rising for a good while longer.

What about earnings? Before the 2002 reforms, most salaries lay in the range of 150-200 won per month. Rent and utilities, though, were virtually free, as were (and are) education and health care. Food, via the PDS, was virtually given away. Now, pay is supposed to be linked to output, though becoming more productive is not easy for desk-bound civil servants or workers in factories that have no power, raw materials or markets.

Rents and utilities have gone up, though not by crippling amounts. A two-bedroom flat in Pyongyang including electricity, water and heat costs just 150 won a month—that is, about a tenth of a euro.

Earnings have gone up much more: a waitress in a Pyongyang restaurant earns about 2,200 won a month. A mid-ranking government official earns 2,700. A worker at a state farm earns in the region of 1,700, a kindergarten teacher the same, and a pensioner gets between 700 and 1,500. A seamstress in a successful factory with export contracts can earn as much as 5,000 won a month. Since that seamstress’s pay equates to barely three euros a month, wages still have a long way to adjust.

The prices of food and other necessities, to say nothing of luxuries, has gone up much more than rent has. According to the WFP, some 70% of the households it has interviewed are dependent on their 300 gram PDS ration, and the WFP itself is targeting 6.5m vulnerable people out of a total population of some 23m. Not all suffer equally: civil servants in Pyongyang get double food rations from the PDS.

There are some encouraging stories. In Pukchang, a small industrial town 70km (40 miles) north-east of Pyongyang, Concern, an Irish aid group, has been replacing ancient, leaking and broken-down water pipes and pumps, and modernising the purification system. This has pushed the amount of clean water available per person per day from 80 to 300 litres. Kim Chae Sun is a manager at the filtration plant, which is now more efficient. Before July 2002 she earned 80 won a month. Afterwards she earned 3,000 won. Now she earns 3,500.

As Mrs Kim speaks, three giant chimneys belch smoke from the power station that dominates the town. All workers have been told they can earn more if they work harder, but certain groups have been told they will get even more money than everyone else. In energy-starved North Korea these include miners and power workers. Mrs Kim says her husband, who works in the power plant, earns an average of 12,000 won a month. Her rent has gone up from eight to 102 won a month, and in a year, she thinks, she will be able to buy a television or a fridge.

A lot of people, in fact, are buying televisions. The women who sell the sets from crowded Tongil market-stalls get them from trading companies which they pay after making a sale. The company price for an average set is 72,000 won, the profit just 1,000 won. After they have paid for their pitch, the traders can expect an income of 10,000-12,000 won a month.

Mystery sales
Which makes for a puzzle. Who can afford a good month’s salary for a locally made jacket in Tongil, costing 4,500 won? How come so many people are buying televisions, which cost more than two years of a civil-servant’s pay? How come the number of cars on the streets of the capital has shot up in the past year? Pyongyang still has vastly less traffic than any other capital city on earth, but there are far more cars around than a year ago. Restaurants, of which there are many, serve good food—but a meal costs the equivalent of at least a white-collar worker’s monthly salary. Many of these restaurants are packed.

Foreign money is part of it. Diplomats and aid workers say many new enterprises seem to have opened over the last year. Nominally they are state-owned, but sometimes they have a foreign partner, often an ethnic Korean from Japan. The majority are in the import-export business. Some have invested in restaurants and hotels and some in light industry. Thanks to the 2002 reforms, these firms have a degree of autonomy they could not have dreamed of before. An unknown number of people also receive money from family abroad, but there are still no North Korean-owned private companies.

Farmers are among the other winners: they can sell any surpluses on the open market. But two out of three North Koreans live in towns and cities, and only 18% of the country is suitable for agriculture. The losers include civil servants, especially those outside Pyongyang who do not get double food rations and have no way to increase their productivity.

Factory workers have it the hardest. A large proportion of industry is obsolete. Though Pyongyang has electricity most of the day, much of the rest of the country does not. Despite wild talk of a high-tech revolution, the country is not connected to the internet, though some high-ups do have access to e-mail service. In the east of the country lies a vast rustbelt of collapsing manufacturing plants.

Huge but unknown numbers of workers have been moved into farming, even though every scrap of available land is already being cultivated. The extra workers are needed because there is virtually no power for threshing and harvesting and no diesel for farm vehicles. This requires more work to be done by hand. Ox-carts are a common sight.

The innocent suffer
Markets are everywhere. But this does not mean that there is enough food everywhere. In Pyongyang, where there are better-off people to pay for it, there is an ever-increasing supply. Outside the capital, shortages are widespread.

No one knows how many died during the famine years of 1995-99; estimates range from 200,000 to 3m. In Pukchang, officials say that 5% of children are still weak and malnourished. In Hoichang, east of Pyongyang, schools and institutions tell the WFP that about 10% of children are malnourished. Masood Hyder, the senior UN official in North Korea, says that vulnerable households now spend up to 80% of their income on food.

And yet some things are improving. Two surveys carried out in 1998 and 2002 by the North Korean government together with the WFP and Unicef showed a dramatic improvement in children’s health between those years. The proportion of children who fail to reach their proper height because of malnutrition fell from 62% to 39%, and the figures are thought to be still better now. However, Unicef says that though children may no longer die of hunger, they are still dying from diarrhoea and respiratory diseases—which are often a side-effect of malnutrition.

To a westerner’s eye, a class of 11-year-olds in Hoichang is a shocking sight. At first, your correspondent thought they were seven; the worst-affected look to be only five. Ri Gwan Sun, their teacher, says that apart from being stunted some of them still suffer from the long-term effects of malnutrition. They struggle to keep up in sports and are prone to flu and pneumonia. They are also slower learners.

Pierrette Vu Thi of Unicef says that North Korea’s poor international image makes it hard for her agency, the WFP and others to raise all the money they need. The country is in a chronic state of emergency, she says, and to get it back on its feet it would need a reconstruction effort on the scale of Afghanistan and Iraq.

Such bleak talk is echoed by Eigil Sorensen of the World Health Organisation. He says that health services are extremely limited outside the capital. Medicines and equipment are in short supply, large numbers of hospitals no longer have running water or heating and the country has no capacity to handle a major health crisis.

None of this is likely to change very fast. With no end yet to the nuclear stand-off between North Korea and the United States, American and Japanese sanctions will remain in place. And nukes are only part of it. Last week the American State Department said it was likely that North Korea produced and sold heroin and other narcotics abroad as a matter of state policy. North Koreans who have fled claim that up to 200,000 compatriots are in labour camps. North Korea denies it all.

Reform, such as it is, has plainly made life easier for many. But rescuing the North would take large amounts of foreign money, as well as measures more far-reaching than have yet been attempted. At present, there is no way for the government to get what it needs from international financial institutions like the World Bank. Such aid as comes will be strictly humanitarian, and investment in so opaque a country will never be more than tentative. Domestic reform on its own cannot fix an economy wrecked by decades of mismanagement and the collapse of communism almost everywhere else.

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Beyond a Wall of Secrecy, Devastation

Sunday, October 19th, 1997

By Keith B. Richburg
Washington Post Foreign Service
Sunday, October 19, 1997; A01

Rare Closeup Reveals a North Korea That No Longer Functions

HAMHUNG, North Korea — A visit to this remote and desolate city near North Korea’s eastern coast provides a rare glimpse of the country’s near-total economic collapse. The crisis is over food — or the lack of it — but the country’s problems run much deeper, to the core of a socialist system that simply has ceased to function.

You can start at Hamhung’s local hospital, a dilapidated, cavernous 1,000-bed facility without lights, where the stench of urine fills the dark corridors, and patients recovering from surgery writhe in pain on dirty sheets in unheated rooms. There are no antibiotics, no intravenous drips and no stretchers, so workers carry patients on their backs. There were only 250 patients during a recent visit; few sick people bother coming, since the hospital has no food and no medicine.

“We have a shortage of anesthesia, so the patients have to go through pain during surgery,” said Dr. Lee Huyn Myung, as he points to a man gripping his mattress after a colon operation. Most of the patients have rectal, stomach or liver problems, the result of slow starvation, he said. Almost all are malnourished.

From the hospital, travel across this city past gray cement buildings that look half-finished or simply abandoned, past lots strewed with broken-down Soviet-era trucks that cannot be started because there are no spare parts. Then drive down narrow, winding mud roads until you reach the Hamhung orphanage and talk to its director, Choi Kwang Oak.

The orphanage is divided into several small rooms, with playpens for the smallest infants. Almost all the children are malnourished, with browning hair, bald patches on their scalps and sores on their heads and faces. The most severely malnourished are listless and unresponsive.

There are 198 children under age 4 at the orphanage, and about 20 percent are expected to die because they arrived too late to be helped. About 70 percent of the children here were orphaned when their parents died of malnutrition or disease, Choi said. The other 30 percent simply were abandoned and left for dead by parents too poor and too hungry to feed them.

“Some parents just put them outside on the street and leave them to nature,” Choi said. “Sometimes people pick them up and bring them here.” And other times? “They just die.”

The orphanage is surrounded by high hills covered with graves and stone markers. It is an old burial ground, she said. But there are also many new graves.

The scenes of deprivation and hardship go on and on. There is a massive 1950s-era hotel in the town, but it is cold and apparently empty. Since power is rationed, the electricity has been turned off.

There are factories here, but they stand idle. No smoke comes from the chimneys; there is no activity inside the gates. Outside, people mill around, apparently with little to do. Nearly everyone here — hospital workers, hotel employees, even the official government guides — talked openly about the fuel shortage and lack of electricity.

And not even the capital, Pyongyang, about 120 miles to the southwest, is immune from the hardship, despite long being maintained as a showcase city for outsiders to witness the apparent success of the country’s socialist system. Diplomats and aid workers say some parts of the city have been without water for days. Electricity is strictly rationed, and floodlights are turned off at some of the towering monuments early in the evenings. By 10 p.m., the city is plunged into darkness, with no street lights on and no lights visible from the surrounding high-rise apartment buildings.

What you also see are bicycles. Visitors to North Korea before the famine marveled at the lack of bicycles on the streets, even as people walked for miles or waited endlessly for buses. Bicycles were officially discouraged, since they promoted individualism and could allow people to move more freely. But now that fuel imports from the former Soviet Union have stopped, and with North Korea lacking hard currency to buy what it needs on the world market, many people use bicycles since buses sometimes do not run.

Last week, U.S. Rep. Tony P. Hall (D-Ohio) and this correspondent were permitted an unusual look behind the regime’s wall of secrecy, traveling into areas rarely seen by outsiders, and never by an American journalist. In addition to Hamhung, which we reached in an old Soviet-made helicopter, we also took a 3 1/2-hour drive north from Pyongyang on the country’s main north-south highway into the rugged mountains of Chagang province to the small town of Tongsin, stopping briefly along the way in a slightly larger town, Huichon.

From the air, the extent of the drought damage was apparent — dry brown earth in many areas, as well as dried-up riverbeds and hills that had been cleared of all their trees. Years of overuse of petroleum-based fertilizers have destroyed much of the arable land, experts say, and hills have been stripped of their topsoil because farmers use it to cover paddy fields, causing increased flooding in the plain.

On the ground, the damage becomes more evident. Buildings look abandoned or unfinished until, on closer inspection, you see faces in the holes where the windows should be, and you realize the buildings are occupied. Huichon, particularly, looked like a ghost town — sprawling factories fallen into disuse, cement buildings missing large sections and darkness everywhere because there is no electricity.

In Tongsin, more a large village than a town, the local hospital was washed away in last year’s floods, and the makeshift one built on the same site from the debris has a few patients but no medicines, heat, or supplies. Three teenage girls were checked in because they were starving; from their body sizes, they looked more like 5- or 6-year-olds, with normal-sized heads for their age but tiny necks and limbs.

What emerged from the three-day trip, conducted mostly in the presence of government escorts, was a snapshot of a country in economic free fall and a surprising willingness on the part of the authorities to allow outsiders to see even the worst of the crisis — like the hospital in Hamhung.

“The most difficult part as a doctor is we could treat them well if we had food and medicine,” said Lee, the deputy director of the hospital in Hamhung. “We know how to treat them — but we can’t.” Many patients die here, but Lee says he cannot disclose the figure because death rates are kept secret in this strictly controlled society.

“What you saw is pretty widespread,” said O. Omawale, the special representative in North Korea for the United Nations Children’s Fund. “I have seen kids with IV drips, with tubing you wouldn’t put in your car, and the [fluid] reservoir is a bare bottle.”

North Korea’s predicament largely has been portrayed as a massive food shortage brought on by twin natural disasters — destructive floods last year followed by this year’s drought and record-high summer temperatures. But what was revealed on this trip is that the food crisis is just part of an overall breakdown of the country’s state-controlled and centrally planned system. It has been a long and painfully slow descent that began with the collapse of the Soviet Union in 1991 and the loss of invaluable subsidies, the major petroleum supplier, and the principal market for exports.

In Hamhung, Lee was asked how long the hospital had been in its state of collapse and shortages. The deputy director replied, “It started six or seven years ago, but it became worse this year.” Six or seven years ago would date the decline to the time the Soviet Union collapsed.

Relief workers in Pyongyang seem in agreement that the food crisis, reaching famine proportions in some areas of the remote and mountainous north-central provinces, is just one more tangible sign of a total systemic collapse. “It’s a large economic crisis, but it’s not being addressed,” said Christian C. Lemaire, the resident representative of the U.N. Development Program. “All we want to do is talk about the food problem.”

Neither, it seems, does the North Korean government have a strategy for what to do to stop the free fall.

One of the world’s last Marxist states, North Korea in many ways resembles a theocracy more than a doctrinaire socialist state, with the country’s late founder and revered “Great Leader,” Kim Il Sung, as its high priest. His portrait still hangs everywhere — even over the hospital in Hamhung — and the north-south highway is lined with billboards extolling his exploits.

Kim’s guiding philosophy is called juche, or self-reliance, and it propelled the country’s headlong rush to industrialize in the 1950s and ’60s. It also has made it more difficult for North Korea’s secretive rulers to admit to outsiders the extent of the crisis and to ask for outside help.

On Oct. 8, three years after the death of Kim Il Sung, his son, Kim Jong Il, officially took over leadership of the ruling Korean Workers’ Party. Now some analysts are wondering whether the younger Kim might be willing to break from some of the country’s socialist practices and adopt the kind of reforms needed for the country to survive.

Some relief workers here claim already to see some early, tentative signs of an opening. For one, they say, there are now six foreign relief agencies based in Pyongyang and the outlying provinces, while a year ago there were none. The workers’ movements are restricted but, they say, they are slowly making progress in persuading authorities to allow them access to more places.

John Prout, deputy director of the World Food Program in North Korea, said his group had been to 110 of the country’s 209 counties.

There are other small signs, relief workers say. Farmers in the hard-hit northern provinces, particularly near the Chinese border, have been told to fend for themselves, allowing them to trade privately with China. With help from the U.N. Development Program, there have been a few scattered experiments with “micro-credit,” providing money to individual households to buy chickens or goats and allowing them to sell the eggs or milk on the open market.

Some North Korean farmers are said to be “double-cropping,” or planting twice each year — a practice long forbidden by Kim Il Sung. And some North Korea analysts in the United States report that massive collective farms have been reduced in size.

On the helicopter trip across the northern mountains, a few small and scattered patches of green were spotted, suggesting that some farmers in remote areas were starting private plots. In some villages, beans were being grown on makeshift terraces in back yards.

“Living here you can really see things change,” said Lemaire, the UNDP representative. “But it’s not change that’s coming from the top. It’s coming from the base.”

A hint of the continued hard-line views of top North Korean officials came during the trip. In one meeting, last Tuesday evening, Deputy Foreign Minister Kim Gye Gwan warmly thanked Rep. Hall for U.S. food aid. “We are grateful to the United States government for the several tons of humanitarian food aid as well as the active efforts of the NGOs,” or nongovernmental organizations, Kim said. But a few minutes later, Kim told Hall that North Korea and the United States “are in a state of hostile relations.”

No one is predicting that the hardships will lead to any kind of popular disaffection with the regime — and in fact, many here believe attitudes will only harden.

The personality cult built up around Kim Il Sung remains deep and pervasive, and now officials seem to be trying to transfer some of the popular affection from father to son.

In a rare interview, Foreign Minister Kim Yong Nam referred to Kim Jong Il as “the people’s leader, who is acknowledged as a man of ability,” a man “who has produced immortal exploits,” a general who “enjoys the absolute trust and support of our people,” and who embodies “the destiny of our nation as well as the future of our country.”

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