15 february 2011

Prime Minister Vladimir Putin chairs a meeting on modernising Moscow’s healthcare system in 2011 and 2012

Vladimir Putin

At a meeting on modernising Moscow’s healthcare system in 2011 and 2012

“Regional programmes must make healthcare more affordable. It is necessary to introduce new standards that can guarantee quality and effective care – including diagnostics, all required procedures, and the appropriate provision of pharmaceuticals. And Moscow should naturally take the lead in introducing these new healthcare standards.”

Transcript of the beginning of the meeting:

Vladimir Putin: Good afternoon, ladies and gentlemen,

As you know, over the next two years, we will be carrying out a large-scale social project to drastically modernise the healthcare system across Russia's regions.

Last year, we launched the pension reform, raising pensions by almost 46% year-on-year. Now we are embarking on a no less important social project – the modernisation of Russian healthcare. As you can see, the government is paying special attention to this issue. We try to be in constant touch with the regions, where most of the work will be taking place, and with the professional community, so as to solicit their opinions on the issue. As Mr Sergei Sobyanin has told me, the developers of the healthcare modernisation programme for Moscow are present here today.

I would like to emphasise once again that regional programmes must be carried out as thoroughly as possible. And for this to happen, first, they should be developed as thoroughly as possible. These programmes should have a palpable effect, so that people can see real changes in the performance of clinics and hospitals. We have asked regional governments to review their spending on the maintenance and repair of clinics and hospitals, and to be particularly attentive while entering into agreements with contractors and suppliers, because it will be critically important to meet the timelines in place for repairs and supplies, and to ensure the proper quality of all such projects.

The federal government has drawn up several documents setting maximum prices for repair works. I am sure that all concerned parties are already aware of these regulations, which were issued by decree of the Ministry of Regional Development and others. I believe that the use of these reference points will improve financial discipline across regions, ensuring that funds are spent in a responsible manner. And these are very substantial funds. I’d like to remind you that the federal government is allocating a total of 460 billion roubles for the entire country. We have never allocated so much at any one time for a specific social programme, especially in healthcare. Naturally, we must do our best to ensure that these funds are used in a reasonable and effective manner. We will need to set a vast number of clinics and hospitals in order – providing them with modern equipment, getting them to adopt new information systems and new healthcare standards, and raising wages in the sector.

Today we will review how Moscow plans to address these problems. We were supposed to launch this work at the beginning of the year but it's already mid-February. We must start this work now. If we just continue to adjust the plans, we won't get started until summer. This happens too often, and then it'll be time to prepare for the New Year... So we must start now.

This programme is critical for Moscow, where 14.5 million people receive medical aid annually. It is very important to launch this programme promptly and efficiently. Given that 14.5 million people can benefit from it, our goals are more than justified. According to the Ministry of Healthcare, a substantial part of the funds allocated through the healthcare modernisation programme, 10% or 48 billion roubles, will go for Moscow.

In addition to this, the city of Moscow will allot an additional 65 billion roubles over two years. Overall, Moscow's healthcare system will receive 114 billion roubles within this period. Over 78 billion will be spent on infrastructure, 30 billion on the adoption of the new medical standards and some 6 billion, or 5.7 billion to be exact, on information management.

As you can see, this is a very ambitious programme, not only in terms of funding but also in scope. Moscow is the largest Russian metropolis and one of the largest cities in Europe. We are well aware of this and are proud of it, and it's really something to be proud of. At the same time, this requires that Moscow's social systems and healthcare should be up to international standards.

Moscow has always had one of the best healthcare systems in Russia. There are major federal research centres and leading medical universities and colleges here, some of which have their own clinics. Local wages are some of the highest in Russia. At the same time, spending on healthcare here is greater than in any other region.

Despite the obvious Moscow advantages, there are problems, in particular, a lack of qualified doctors and nursing staff, as well as medical equipment. Patients have to wait too long for an operation or an examination. Many facilities haven't been refurbished since Soviet times. For example, the Pervaya Gradskaya hospital was last upgraded 30 years ago. People lie in the halls since there is inadequate room in the wards. And the wards themselves are stuffy and just unfit for patients.

The condition of many facilities is below the level of acceptability. Clearly, there are also many nice, modern centres in Moscow, both government-funded and private. There are excellent centres that comply with European standards. But most Moscow clinics and hospitals – I'd like to stress, most of them – where ordinary people go, need attention from Moscow's authorities and the federal government.

Incidentally, last summer's heat showed that many clinics are not prepared to operate under these extreme conditions. They aren't even equipped with air conditioners, like here, or other vital infrastructure systems, even in the resuscitation wards and operating rooms. It's awful.

It's no surprise that less than 50% of Moscow residents are satisfied with the quality of healthcare. The statistics have revealed a very negative trend. The number of cardiovascular, endocrine and cancer diseases is growing. This is why it is necessary to determine what to spend our funds on and how to use them properly and for the benefit of the millions of Moscow residents and Russian citizens that have found themselves in Moscow for one reason or another. This issue appears especially important now that we have launched the programme for integrated medical insurance policies, which will be valid in all regions. It does not matter where a person has come from, he or she must be able to receive medical aid at any Moscow clinic or hospital.

Here's what I'd like to draw your attention to. First, regional programmes must make healthcare more affordable. We have to introduce new standards that can guarantee quality and effective care – including diagnostics, procedures, and the provision of pharmaceuticals. And Moscow should naturally take the lead in introducing these new healthcare standards. We should also eliminate the humiliating need to wait in line. I've raised this issue more than once. The procedure of making appointments and appointments proper should be organised in the most convenient manner for patients. We need to take advantage of information technology here. All patients should have electronic medical cards. Such systems have been adopted in many regions, proving to be very effective.

Second, we will purchase the most advanced medical equipment through this programme. If we have to buy equipment, it should be the latest and most effective equipment. This is going to be a true technological breakthrough. We will also need to teach people to use this equipment, organising internships and training courses for them. Advanced training for medical specialists also needs to be improved.

Third, there are many municipal and federal medical centres in Moscow. They should not duplicate each other's efforts, especially in general healthcare. Medical centres at universities and colleges should not operate as typical municipal clinics or hospitals – it's just ineffective. They should focus on research, developing and introducing new treatment methods and provide high-tech medical services. At the same time, both federal and municipal clinics should be integrated into the healthcare system so it can function seamlessly and at each stage, from an appointment at a clinic to inpatient treatment at a good centre and to subsequent rehabilitation. The creation of this system is one of the major challenges for the Ministry of Healthcare and the Moscow government.

Fourth, we should pay special attention to children's healthcare. To my knowledge, Moscow plans to spend 26% of the total allotment for the industry on children's healthcare. I support this decision. It is necessary to create proper conditions for parents to stay with their children at inpatient wards, if possible. This is common global practice, and it's also done in Russia, which is good, but this practice should be expanded.

Ultimately, I'd like Moscow Mayor Sergei Sobyanin to take personal control of this programme, as agreed. I discussed it with Mr Sobyanin in detail yesterday. We decided to convene this meeting today, and invite specialists to solicit their opinions. Yesterday Moscow government officials and Healthcare Ministry officials were to finalise this programme. Let's discuss it in greater detail now.

Mr Sobyanin, please.

Sergei Sobyanin: Thank you, Mr Putin. Indeed, the programme has no precedent. Moscow has always invested quite heavily in its healthcare system, but the allocations earmarked [under this federal programme] are unprecedented. As is the sheer fact of a federal programme allocating so much money for Moscow’s needs. We’ve never seen such amounts invested in our healthcare sector before.

As you have said, Moscow will receive a total 48 billion roubles in allocations. A handsome sum, isn’t it? That kind of budget, supplemented with money from the regional purse, will make the programme a serious undertaking, I think.

As you’ve rightly noted, the number of people in need of healthcare in Moscow is 14.5 million – close on 15 million. But only about 10 million have medical insurance, which means that every third patient is a visiting non-resident. That’s a lot of strain for Moscow’s healthcare network. In order to cope, it has to be highly efficient. And it’s not.

You made a fair point that… Even if we take one hospital as an example, we’ll see that some 60% of its fixed assets are dilapidated and in need of major repairs, renovation, or reconstruction.

In central Moscow, clinics are often housed in registered historical buildings, ill equipped for modern healthcare needs. This makes repairs and construction works all the more difficult. But we must address this problem at all costs.

Equipment depreciation in the sector has come to 68%, and all the old facilities need to be replaced. That’s a lot of work to do, and we won’t be able to accomplish it within the framework of a single programme, however ambitious.   

Vladimir Putin: We’ve looked around here… These x-ray machines, how old are they? Twenty years or so?

Sergei Sobyanin: These have been around since 1983.

Vladimir Putin: Yes, since 1983. [And those] since the early ’90s.

Sergei Sobyanin: And it’s not an isolated case. Those who have come here today for a hospital visit say that the situation is quite typical for Moscow. Most public criticism of the healthcare system is legitimate. Although when I talk with patients, they often say they like their doctors and are quite happy with the care they receive. That said, the facilities need renovation. 

This is why, along with this two-year modernisation programme, which we will execute in collaboration with the federal government, we propose the development of a municipal healthcare programme – one intended for a period of five years.  It is intended to follow through on what we fail to fix within the next two years – and, indeed, it’s next to impossible to fix all there is to fix in two years’ time. We’ll continue investing heavily in upgrading the sector.

As you have said, the modernisation programme envisages 114 billion roubles in total investments, with 78 billion to upgrade infrastructure. The following is the breakdown on the latter amount: 16 billion roubles for major repairs, 39 billion for equipment purchases, 7.9 billion for the completion of ongoing construction projects, and 5.3 billion for regular maintenance. That’s a lot of money, and it should be distributed among dozens of different sites, or even hundreds in the case of maintenance.

Our HQ groundwork will involve setting deadlines, spelling out decision-making procedures, preparing technical assignments, and so forth. This is why, Mr Putin, we approved a municipal programme for the renovation of medical facilities at a [city] government session earlier today, with budgets for some specific sites already factored in.

Also, we continue renovation works launched under previous programmes, making additional financial injections. We currently have 21 sites under construction or being repaired.

We’ve earmarked substantial funds for 700 sites in need of minor repairs, with invoices ready for about half of them.

In the next few weeks, we’ll have to draw up a schedule for works on each of the sites. Within two to three weeks’ time, we’ll need to finalise the programme together with the Ministry of Healthcare and Social Development, setting a timetable on finances to be disbursed from the Federal Medical Insurance Fund.

It’s important to synchronise all of these activities. In the weeks ahead, we’ve got to prepare schedules for every project to be upgraded in 2011 and 2012.

As you have said, these efforts should bring solutions to some outstanding public health problems in Moscow, bringing down the cancer-related mortality rate, reducing deaths from cardiovascular disease, and improving paediatric healthcare. These will be the programme’s priority areas, and most of the allocations will be sent to hospitals involved precisely in those areas.

There’s also the problem of outpatient care. In Moscow, it’s felt most acutely, perhaps. In this case, too, we’ll be looking beyond the framework of the modernisation programme to see what else can be done.

We discussed this at today’s [city] government session, and we decided to allocate an additional 3 billion roubles for repairing clinics that provide outpatient treatment, renovating their façades, and so on. It’s important, isn’t it, that the building housing a clinic should have a good-looking façade and that its grounds look nice? 

And, of course, we’ll have to make sure that all medical facilities are adequately equipped, including high-tech apparatuses. We’ll be working on that in the months ahead. Thank you.

Vladimir Putin: Ms Golikova has the floor.

Tatyana Golikova: Mr Putin, ladies and gentlemen.

At our previous working meetings, we discussed the programme in sufficient detail with representatives of the Moscow City Hall and drew a conclusion to it. I would not like to speak about our conclusion at length because it will be submitted to the City Hall as early as today. I would like to concentrate on critical problems, mainly proceeding from last year’s statistics on disease incidence and death rates, but also pertaining to the state of Moscow’s healthcare.

I am eager to see the huge funds and efforts that the City Hall and Mr Sobyanin have been contributing to the programme bear fruit by improving healthcare and increasing access to it. Why am I beginning in this manner? We have summarised citizens’ complaints of inferior or inadequate healthcare in Russia for last year, and, regrettably, we have seen that Moscow accounted for 60% of them. The success of all measures in this field depends on the success of the programme.

As for quality indices of healthcare, we see the following priorities. According to the Federal State Statistics Service, the death rate in Moscow increased by 4.4% last year and by roughly 1% on the national average due to heat and drought in July and August. Apart from the general rise in the death rate, the number of fatal traffic injuries grew by 7.5% and the general toll of traffic accidents by 10.2%, while it is decreasing countrywide. The death rate of tumour-related illnesses has increased by 5.5% in Moscow, compared with 0.3% nationwide. What’s worse, we received very alarming figures for Moscow: cancer-related death rates increased by 3.8% against the 2.5% fall in the national average. These figures show the state of healthcare in Moscow.

The overall mortality structure is more or less typical and reflects the situation across Russia: cardiovascular diseases, cancer, diseases of the alimentary, respiratory, and urogenital systems, accidents, and violence. I would like to focus on violent death and the overwhelming number of murders and suicides in Moscow. It increased by 6.9% last year against 2009. This is largely due to Moscow’s federal functions.

We would like to call attention to the medical aspect of this problem. We deem it necessary to establish emergency psychological aid in the city’s clinics and disease prevention centres – patients under psychological duress had nowhere to turn before last year.

Primary medical and sanitary care also offered very alarming indices in the preceding years. I would like to call attention to these diagnostics. As we summarised last year’s health screening in Moscow for this meeting, we saw that disease detectability in Moscow was 90% below the national average. Unprecedented!

We made a statistical summary of disease diagnosis in Moscow. I have to assume that either preventative checkups involve absolutely healthy people and the same persons are examined year in and year out, or some negative factors come into play, which I wouldn’t like to mention here. However, I mentioned these indices intentionally because they reveal the drawbacks of primary care, which caused a 2.1% increase of cardiovascular and a 6.6% increase of respiratory disease incidence. Incidence and mortality grew hand in hand last year. Mortality increased for absolutely all diseases, as I have said.

And why? We believe that one of the reasons is the high plurality of general practitioners, as Mr Sobyanin said. We have a high rate of outpatient visits – 13.1 per person, or 45% above the national average. The situation reveals inefficient personnel placement and so demands assessment, so I would like to see the programme pay special attention to outpatient clinics operating as primary care offices.

I would also like to address the problems that Mr Sobyanin has mentioned, proving my point with figures. The uneven distribution of clinics is characteristic of Moscow. Some clinics cater to 18,000 persons, while others see 60,000, according to municipal statistics. Naturally, doctors cannot cope.

The City Hall has made a proposal on its programme, which I find very reasonable, to establish interregional centres employing specialists. This is the right thing to do, but the arrangement demands a clearly specified list of diseases that such centres deal with, and a smoothly running system for patient care.

Next come the problems of emergency medical services. Their burden grows with the inefficiency of disease prevention and primary services. When primary services don’t fulfil their duties in full, ambulances are called more often. We know that such calls became more frequent last year. I think the problem demands attention, and, in particular, emergency care should be developed in outpatient clinics. On the other hand, we should develop a system of stand-by treatment facilities, which are far fewer [in Moscow] than in the whole country.

Moscow has another unique quality – a large number of federal health institutions subordinate not only to the Ministry of Health but also to the army, law enforcement bodies, the Russian Academy of Medical Sciences, and others. Mr Putin, you were quite right to say that we should not fund and use the same facilities twice. If the mandatory health insurance system incorporates federal health institutions, which we want Moscow to do, they will offer quality services on a par with municipal healthcare.

I would like to call our Moscow colleagues’ attention to what we talked about yesterday: a balanced approach to the arrangement (not restructuring) of stock in Moscow hospitals. Hospital treatment of some diseases is not intensive enough, unlike therapy, rheumatology and haematology, for which the load per hospital bed exceeds the number of days in a year. Federal medical institutions have facilities that might be used more intensively.

I will not speak now on a related topic – municipal and federal high-tech healthcare.

There is another issue. I think Mr Sobyanin knows what I have in mind. I mean improving the treatment of socially significant diseases in TB dispensaries and drug abuse clinics. We have firsthand knowledge of the problems of the Moscow TB service and the state of its facilities. Underfunded and underequipped, they cannot offer proper treatment. Such health centres are entirely funded by the government and are outside the mandatory health insurance net due to their social significance. I insist that the City Hall pay close attention to them because many tubercular cases are overlooked – the number of posthumous diagnoses exceeds the national average by 80%.

There are major problems with compound diagnoses, such as AIDS and TB. Statistics for last year are still unavailable, but the figures for 2009 are alarming. TB morbidity among HIV-infected patients is 74 times greater than for non-infected persons – a blood-curdling figure. Despite Moscow’s own resources and federal aid in 2009, not a single HIV-infected patient received chemotherapy that year – I don’t know why.

Then there is obstetrics and paediatrics. Here, I will call your attention only to one detail pertaining to the multi-level arrangement of paediatrics. The system demands the utmost care to be duly organised.

I would also like to say a few words about personnel. I think that the situation demands balancing out primary institutions, such as clinics and interregional centres, and hospitals. We had no such balance last year, nor did we before.

Last but not least, we should think about our healthcare standards. The state guarantee programme is funded better in Moscow than in other regions of Russia. By some indices, its grants exceed the national standards set by the government several times over. That’s good. If Moscow launches healthcare modernisation according to the programme now, it will be the first region to meet the upgraded federal standards, which envisage increased wages for doctors both in clinics and hospitals, improved drug and medical supplies, and everything else implied by its mission.

I would like to say by way of conclusion that, despite Moscow’s problems, despite public criticism (which are understandable in the national capital), the city has greater opportunity than any other part of Russia to succeed in 2013, when the entire system is scheduled to switch to mandatory health insurance. We expect a smooth process of cooperation, and we think that we will succeed.