International aid to North Korea remains far below the humanitarian needs of vulnerable people. This paper examines the trajectory of international humanitarian assistance to North Korea over the last two decades with the focus on its decline in the context of the country’s nuclear standoff and corresponding stringent sanctions. In so doing, the paper addresses major problems associated with North Korea’s reception of foreign aid and operational constraints placed on humanitarian activities in the country. It shows that humanitarian assistance to North Korea has been largely shaped by geopolitical dynamics. A survey of UN reports and statistics also suggests a shifting trend in recent international aid to North Korea. The decline of aid and multiple operational obstacles faced by humanitarian organizations, for instance, have led to a fall in agricultural support and a proportional rise in health and related services. While UN Security Council resolutions include an exemption provision, humanitarian assistance to North Korea has been constrained by stringent sanctions, which have led to adverse consequences for the civilian population. In this regard, the paper suggests some policy directions for international aid to North Korea amidst negotiations over denuclearization, while stressing an urgent need to address the negative impact of sanctions on vulnerable groups in the country.