The historical legacy of North Korea is characterized by occupation and conflict, and economic rehabilitation and then collapse, with tragic and widespread consequences for population health. From the standpoint of the historical determinants of health, this paper reviews the health system in North Korea between 1953 and 2016. Ideology and political relations have been dominant forces in determining the evolution of the health care system and population health. Despite the development of an extensive primary health care system in the country from the early 1960s following the establishment of the DPRK state in 1948, the public health system experienced a major decline in the 1990s, with catastrophic implications for the health and survival of the population. In recent years, evidence has emerged of some important public health gains, particularly through immunization, women's and children's health, and communicable disease control initiatives. This experience demonstrates that, within the overall policy context dominated by the historical and political determinants of health, there remains the capacity for implementation of public health programs that can yield both tangible health benefits for the population in North Korea, as well as assist the health system to edge closer to a regional standard.