BACKGROUND: To gain insights into the socio-economic and political determinants of ill health and access to healthcare in North Korea. METHODS: A retrospective survey using respondent-driven sampling conducted in 2014-15 among 383 North Korean refugees newly resettling in South Korea, asking about experiences of illness and utilization of healthcare while in North Korea, analyzed according to measures of political, economic and human rights indicators. RESULTS: Although the Public Health Act claims that North Korea provides the comprehensive free care system, respondents reported high levels of unmet need and, among those obtaining care, widespread informal expenditure. Of the respondents, 55.1% (95%CI, 47.7-63.7%) had received healthcare for the most recent illness episode. High informal costs (53.8%, 95%CI, 45.1-60.8%) and a lack of medicines (39.5%, 95%CI, 33.3-47.1%) were reported as major healthcare barriers resulting in extensive self-medication with narcotic analgesics (53.7%, 95%CI, 45.7-61.2%). In multivariate logistic regressions, party membership was associated with better access to healthcare (Adjusted OR (AOR) = 2.34, 95%CI, 1.31-4.18), but household income (AOR = 0.40, 95%CI 0.21-0.78) and informal market activity (AOR = 0.29, 95%CIs 0.15-0.50) with reduced access. Respondents who could not enjoy political and economic rights were substantially more likely to report illness and extremely reduced access to care, even with life-threatening conditions. CONCLUSIONS: There are large disparities in health and access to healthcare in North Korea, associated with political and economic inequalities. The scope to use these findings to bring about change is limited but they can inform international agencies and humanitarian organizations working in this unique setting.