The Democratic People’s Republic of Korea (DPRK) has made impressive progress in the past three decades-reducing by one fourth the mortality rate of children under 5 years old from 120/1000 in 1960 to only 30/1000 in the year 1996. The total population of DPRK is 22.8 million, of which 11.6% are under the age of five. The country’s population growth rate is 1.5 per cent per year; one of the rather low rates in among the developing countries. More than 60 percent of the population live in the urban areas.
The DPRK has a well-established curative and preventive health care system with complete coverage of the population. There are some 220 county hospitals, 6,249 ri-hospitals and ri-clinics, as well as at least one referral hospital in each province. For every 10,000 inhabitants there are 30 doctors, 18 nurses and 15 midwives (table 1). Health care is free of charge.
Between 1994 and 1997, the DPRK suffered a series of natural disasters which severely affected the nation. While the organization of the existing health system is impressive there are, however, numerous problems related to the shortage and distribution of resources. The infrastructure is showing signs of deterioration and the maintenance of health and other facilities is becoming increasingly less effective as the economic situation worsens thus compromising the health care and delivery system.
Preventive as well as curative services, with an integrated lifecycle approach and comprehensive care, need to be restored.
Child Survival: Reviving the EPI
The DPRK’s previous success in achieving immunization coverage of over 99 per cent for all antigens are now threatened by the closure of their factories producing vaccines and the country’s inability, financially, to procure vaccines from the international market. The cold chain is virtually non existence compounded by unreliable or nonfunctioning electric supply. Consequently, children are not being regularly vaccinated. The expanded program on immunization (EPI) has therefore become an urgent priority to protect children against preventable diseases.
A recently conducted Multiple Indicator Cluster Survey indicate that a large majority of children aged 12-23 months did not receive the necessary vaccination during their first year of life.
Data from the vaccination cards of 294 children (94.3%) of between 12 and 23 months showed that BCG coverage was 63.9%, and the DPT3 coverage was only 37.4%. Measles coverage had also fallen to 34.4%. The OPV3 coverage, however, stood at 76.5%; this is attributed largely to the NIDs observed with WHO and UNICEF assistance in 1997 and 1998.
MICS also looked at the immunization status of a total of 563 pregnant women and mothers of children less than 2 years. Only 59.7% of women had their cards at home. The information analyzed from the cards revealed that whereas a total of 91.1% women were given one dose of tetanus toxoid (TT), only 4.6% had received two doses of TT.
Also, DPRK has a very complex vaccination schedule with several contacts and doses of vaccine (table 2)
Regularizing the immunization program to achieve sustainable coverage above 80 per cent for children under one year of age in the country, has emerged as the highest priority under the DPRK-UNICEF Program of Cooperation. Towards this objective, UNICEF in collaboration with WHO, will assist the government in following areas:
1 Cold Chain
The cold chain in the country is largely ineffective due to equipment shortage and unreliable electricity supply. Ensuring adequate storage at the central level and strengthening cold chain in the provincial and county level is to be emphasized.
Total cost: $60,000
Total cost: $100,000.
Total cost: $110,000 (including freight)
d. Freezers and refrigerators are also being procured by WHO to be placed at the county level for vaccine storage and distribution to the Ri Clinic. Ri clinics are supplied with cold boxes to transport vaccines from the county. Vaccinations at the Ri are done on prearranged dates.
There are approximately 430,000 children born each year. Presently, all the vaccines, along with the syringes and safety boxes, will need to be imported to fully immunize all new born. Additional supplies of vaccines will also be required to vaccinate children who have missed vaccination earlier due to an interruption in the routine immunization programme. The total vaccine requirement, including the wastage factors, is given below.
Total cost: $1,200,000 (inclusive of freight)
Total cost: $299,000 (inclusive of freight)
Total cost: $150,000 (inclusive of freight)
Total cost: $144,000 (inclusive of freight)
To strengthen the immunization programme of the country, it is necessary to ensure that the nation has the capability to deliver vaccines to the provinces and to evaluate and monitor the implementation of the programme in the fields.
Total cost: $300,000 (including freight)
(note: 500 vaccine thermometers, 100 sterilizable syringe kits and 1,200 safety boxes (at an estimated cost of $12,000) have already been ordered under the 1998 funding to arrive in early 1999 to assist the immunization program.)
4 Monitoring and Evaluation
The immunization program will be monitored and evaluated through process indicators, such as immunization rates and impact indicators, such as reduction of infant and child mortality, and reduction in incidence of targeted immunizable diseases. Revision of the current EPI strategy, schedule and guidelines will also be emphasized.
Programme and the maintenance of the equipment and supplies are to be enhanced.
Total cost: $12,000
Total cost: $ 10,000
Total cost: $20,000
It needs to be pointed out that a similar proposal has been incorporated in the emergency appeal for 1999. UNICEF and WHO have made a joint appeal amounting to $4,993,600 for 1999 ($2,516,600 for UNICEF and $2,477,000 for WHO supported interventions).
The funds provided for EPI and other health interventions under General Resources (GR) for 1999 is only $150,000. Out of this amount, $132,000 has been reserved for the new post of the Project Officer, Health. The remaining $18,000 is for the EPI, Safe Motherhood, and Child Health program activities.
Regularizing the immunization program of the country and achieving high immunization coverage by the end of 1999 is of the highest priority for the government, WHO and UNICEF. The proposed EPI activities are extremely essential in order to revive the EPI in the DPRK.
Since the funds requested through the emergency appeal are not guaranteed and usually become available in small contributions over an extended period, this request is put forward to secure guaranteed and timely funding to immediately implement the above mentioned activities and achieve Universal Child Immunization by the end of 1999.
The natural disasters and the economic difficulties faced by the country has also brought in malnutrition, micronutrient deficiencies, lack of energy for heating during winter, and has adversely effected the water and sanitation system. This has increased the risk of acute respiratory infections (ARI) and diarrheal diseases (DD) amongst children. Ministry of Public Health stated that 4,452 children under five died of diarrhea and 5,088 died of ARI in 1997.
UNICEF, in 1999, aims to reduce the morbidity and mortality due to ARI and DD through support of extensive use of oral rehydration therapy and standard case management for ARI. Assistance to rehabilitate the water supply and sanitation system to full status will also be a major UNICEF program in 1999.
TABLE 3 Cold chain equipment provided in 1997/98
TABLE 2 Existing Immunization Schedule in DPRK
Standard WHO recommended schedule for childhood Immunization.
TABLE 1 Population and medical establishment