Prime Minister Vladimir Putin holds a meeting in Ryazan to review the progress of programmes to improve perinatal care and modernise regional healthcare


“Our goal is to create truly modern medical centres in every sense of the word: from the adoption of high technology to comfortable conditions in the wards. And here much depends on the approach of the government – at both federal and regional levels.”

Prime Minister Putin’s introductory remarks:

Good afternoon, ladies and gentlemen.

There are two important issues on our agenda today. They are both essential for improving the quality and availability of healthcare and guaranteeing our nation’s health. First, we will review the progress made on our project to improve the national network of perinatal centres. And then we will discuss how well the regions are prepared for launching healthcare modernisation programmes.

As far as the issue of perinatal centres goes, the situation is clear on the whole – I discussed it with you in detail at a meeting in Tver in August 2010. It’s been six months since that meeting, and I suggest that today we evaluate the preliminary results in order to see what has been done and how.

I’d like to remind you that there is a plan to build a total of 24 perinatal centres: two of them are federal, and 22 are regional. Between 2008 and 2010, we allocated 19 billion roubles from the federal budget in order to construct these centres and purchase equipment for them. We provided an additional 800 million roubles in 2010 after considering the regions’ requests for funding. In particular, the Trans-Baikal Territory has received 200 million, the Yaroslavl Region 500 million, and the Ryazan Region 100 million.

Eleven perinatal centres have already become operational. We have just visited one such centre in Ryazan. It opened recently, on March 1.

Two centres, in Kaliningrad and Irkutsk, opened their doors to patients in 2009. In 2010, these were joined by another six centres – in Tver, Volgograd, Kirov, Kemerovo, Rostov-on-Don, and Yekaterinburg, as well as one federal centre in St. Petersburg and the Almazov Federal Heart, Blood, and Endocrinology Centre, which opened in September. The Kursk and Ryazan centres became operational in February and March 2011, respectively.

I’d like to emphasise that these and other perinatal centres were created to provide high-tech medical services where the capabilities of ordinary medical centres and maternity hospitals were unable to meet the needs of the most difficult cases.

About 20,000 babies have been delivered in these centres already, and 50,000 women received professional consultation. The effect of these centres is obvious. For example, in the Kaliningrad Region, infant mortality rates fell by over 35% in 2010 alone.

In March, a survey was conducted among patients of these new perinatal centres, and I think you should be curious to learn its results, even more so because the issues pertaining to the operation of these centres fall within the purview of regional authorities. We have just been to one such centre in Ryazan, as I have said. You know, it’s like a medical palace, so to speak. It’s modern, beautiful, well-equipped… It has the most advanced equipment and a team of real professionals – senior doctors and young, promising specialists. It’s not very pleasant to speak about problems, about sad things, of course, but we have to do so because there are still many persistent challenges to overcome. And I would like all of you, especially regional leaders, to pay special attention to them.

For example, several patients complained that they had to pay money to be admitted to the new perinatal centre. In addition, they had to pay for drugs. And I can’t understand how this happens. Why? This was the case in Kirov. Several patients in Irkutsk, Rostov, Yekaterinburg, Kaliningrad, Kursk, and Tver said that they were treated rudely by the staff and that there were no basic appurtenances in the wards, such as kettles, bathrobes, or tables. They also pointed to poor conditions in the wards – either too cold or too hot. Yet these are referred to as modern centres… Furthermore, some of the centres have no drugstores, cafeterias, shops, or payment terminals. There are also complaints about the quality of the food.

So, many areas that are essential to creating a comfortable environment remain unresolved. Few centres offer internet access to patients, which, as we understand, is one of the most convenient ways to keep in touch with their families. After all, these are perinatal centres – modern, high-tech facilities – and video conferencing with families would be a relevant issue. The problem of internet access should be resolved immediately.

I’d like to reiterate that our goal is to create truly modern medical centres in every sense of the word: from the adoption of high technology to comfortable conditions in the wards. And here much depends on the approach of the government – at both federal and regional levels.

It is very important to form strong professional teams by attracting good specialists, doctors, and mid-level personnel. We must do our utmost to make positions at such centres prestigious and to increase the prestige of the profession in general.

As I said at the meeting in Bryansk, we will adjust wages by 6.5% in government-funded sectors on June 1, and we will do our best to carry out such indexations again, by autumn. But then we will also need to raise wages in the industry through healthcare modernisation programmes. Of course, regions should be addressing this issue along with the federal government. It is necessary to set the right budget priorities, provide support to medical personnel and resolve their problems with housing and other social issues.

Nevertheless, there are several good examples to follow. For example, doctors in the Sverdlovsk perinatal centre receive up to 40,000 roubles and mid-level personnel up to 20,000. These are fairly good salaries.

The Kemerovo Region government has been very effective in using mortgages to provide housing to young specialists. Despite budget problems, the Penza Region government made a decision to give doctors bonuses and one-off payments. And these initiatives cannot but be appreciated.

We should also consider how to organise internships and retraining courses for medical personnel. Doctors should have an opportunity to improve their qualifications at leading Russian and international clinics. Unfortunately, only one fourth of the medical personnel of perinatal centres have taken such training courses.

We need to invest money in order to improve specialists’ qualifications, and we need to think about the future. One of the main priorities is the adoption of modern technology in the industry. The centres must be as effective as possible. We should eliminate the need for patients to wait in line and for doctors to fill in endless forms. In this regard, I’d like to note that so far only the Ryazan and Kaliningrad perinatal centres have electronic databases for their case records.

I have just raised this issue with the governor. I appreciate that he provided the necessary money for this project some time ago. Such databases are very convenient for patients and doctors to use. And the main thing is not only that it’s convenient but that it improves the quality of service and care at perinatal centres and other high-tech medical centres because it’s a truly comprehensive information system.

Here, in the Ryazan Region, everyone should be registered and provided with qualified care and prompt consultations.

Now I’d like to say a few words about the new perinatal centres in Voronezh, Krasnodar, Murmansk, Saransk, Saratov, Tomsk, and Yaroslavl. According to the Ministry of Healthcare and Social Development, they are to start operations in Voronezh on June 30; in Krasnodar on March 10; in Murmansk on March 31; in Saratov on May 30; in Saransk on April 30; in Tomsk on March 30; and in Yaroslavl on March 23.

As far as I know, the construction of all these sites has been almost completed by now. But there have been setbacks in putting the facilities into operation, despite the absence of any objective reason for delay.

There should be no difficulty in purchasing and installing equipment provided that there was competent planning.

In Voronezh, for instance, the construction was completed by January 1, but the necessary equipment won’t arrive until April or May, and it will take another two or three months to install. As a result, the centre will be unable to admit its first patients until the end of the summer – in the best-case scenario, that is.

I’d like the governors to take such issues under their personal supervision and report before April 15 on all measures being taken [to expedite the process].

Now on to other issues pertaining to the purchase of equipment. It’s no secret that preference is still given to imports. Until 2008, medical organisations [in Russia] purchased very few domestically-made items. Now the situation is gradually changing, and locally produced equipment already accounts for 11% of the total. That’s still obviously not enough, however, and we should attach more attention to the development of the Russian medical industry. I’ll expand on this later.

I’m sure you know that we’ve adopted a special federal targeted programme [to address the issue]; I’ll return to that programme further down the road.

I’d like to make it clear to regional authorities, manufacturers, and the heads of medical institutions that the government wants and has the capacity to help. But for that help to be effective, we need modern, cutting-edge equipment.

Our enterprises in the medical industry should overhaul their distribution structure and improve the quality of their products to make them more competitive and stimulate consumer demand, as well as upgrade production lines and technology. And we’ll be happy to help them through.

Let me emphasise once again: the government plans to disburse considerable amounts of money in federal allocations for the development of the medical equipment industry and the pharmaceutical sector. More than 120 billion roubles have been earmarked, all in all, including 40 billion in targeted funding for improving the manufacture of medical equipment.

Now I’d like to talk briefly about the cost of such equipment.

Judging by invoices, the same medical appliances may cost different amounts, even if they are ordered from the same manufacturer. There’s a spectacular difference in price by regions, in fact.

Here are a few examples. A German-made incubator for the transport of newborns has been purchased for Irkutsk’s centre at a price of 800,000 roubles, while the same appliance ordered for Perm cost as much as 1.3 million. That’s a difference of 60%.

A German-made endoscopic stand with a full set of surgery instruments has been acquired at 3.9 million roubles for Saransk and 7 million for Kursk. In this case, the difference is 77%. But there are even more startling examples.

A Japanese-made defibrillator has been purchased in Kemerovo for 84,000 roubles while Krasnodar has acquired the same model for 464,000 roubles. That’s quite a gap, isn’t it?

I understand that manufacturing companies prefer some intermediaries over others. It seems like the major manufacturers, which aren’t numerous, are involved in price fixing.

Such a difference [in price]! Those appliances weren’t all bought at the same time, which may be a factor, of course. But 84,000 and 464,000 roubles for exactly the same item – that’s just inexplicable.

It’s unacceptable. I request that regional authorities get the situation under control, keeping in mind that we’re all personally responsible for what happens in this field. I’ve already instructed [relevant agencies] to establish a procedure for setting an initial contractual price. The Ministry of Economic Development, the Ministry of Finance and the Federal Antimonopoly Service should complete that work as soon as possible.

Now on to centres still under construction in Blagoveshchensk, Perm, Kurgan, and Chita. According to officials overseeing the implementation of government resolutions, as of late January 2011, the construction and assembly works on these projects were 75% complete in Blagoveshtchensk, 30% in Kurgan, 72% in Perm, and 44% in Chita. According to the Ministry of Healthcare and Social Development, their respective openings are scheduled for September 10 in Blagoveshchensk, December 1 in Kurgan, August 1 in Perm, and October 1 in Chita. Also, it should be noted that work on the perinatal centre in Krasnoyarsk is proceeding on schedule, and the facility will open its doors as planned, on December 15.

In 2011, a similar project will kick off in Moscow; here it will be known as the Kulakov Centre for Obstetrics, Gynecology and Perinatology.

Quite frankly, there have been serious delays in the construction of the four projects I just cited. The builders have been unable to keep up with the original schedule. In Perm, for example, the delay is eight to eleven months, or almost a year. The situation is similar in the Kurgan Region.

Also, the Amur, Chita, and Kurgan regions failed to deliver on their co-funding commitments. Perm stopped short of investing 208 million roubles released for the project from treasury coffers in 2010, while Kurgan failed to invest 100 million. As of January 1, 2011, regional obligations on construction funding have been fulfilled by a mere 14% in the Amur Region, 17% in Kurgan, and 19.5% in Chita.

In addition, the construction costs vary considerably across the regions. Here, the situation is similar to that of the purchase of medical equipment. I am aware that costs may vary from region to region, but not to such an extent.

In Chita, Blagoveshchensk, and Kursk, one square metre costs around 40,000 roubles to construct. The former two cities are in Russia’s Far East, mind you, where the cost of living is generally much higher than elsewhere in Russia.

Yet, in Volgograd and Yekaterinburg, the price of one square metre is 60,000 roubles, whereas in Perm, it’s 70,000.

We should carefully analyse all of these figures and call upon those in charge to give account for cases in which there is no valid justification [for overpricing].

In concluding, let me again stress that we are implementing a highly important and significant project aimed at maternity and infancy protection as well as the advancement of Russian high-tech medicine. So I’d like to ask all the governors to treat this project as a priority.

Our efforts to protect maternity and infancy are part of a larger demographic programme designed to increase the birth rate. Each of us is aware of how important this area is for the future of our nation.

Your work should not stop once the centres have been successfully opened. You will need to monitor their development, tackling problems faced by their staffs and using the potential of these facilities to improve the healthcare sector as a whole.

Speaking of salaries, Ryazan Region Governor Oleg Kovalyov has cited statistics indicating that doctors working at perinatal centres are paid as little as 12,000 roubles per month, while paramedics’ pay is even smaller, around 9,000 roubles. According to our estimates, the transition to the new system and the successful implementation of the healthcare modernisation programme will lead to a 28% increase in doctors’ pay and a 21% increase for paramedics. That is in addition to a variety of bonuses. In Ryazan, this will add up to 24,000-25,000 roubles or more for doctors and 12,000 roubles for paramedics.

This problem will not be solved the same way in every region and locality. The modernisation programme provides for the increase of medical salaries along the way. So please make sure that the pay everywhere is raised as it is due.

Now let’s turn to the regional healthcare modernisation programmes, which is the second item on today’s agenda. We discussed this in Ivanovo in 2010, in Kaliningrad last December and in Moscow in February.

On March 4, the government finished reviewing all of the regional programmes that were submitted to us. Our review was rigorous, and it has revealed several fundamental issues. For example, it has revealed that some regions are not following the provision of the programmes that stipulates that no less than 25% of the funds are for the modernisation of obstetrics and child health services. The Primorye Territory, as well as the Volgograd and Sakhalin regions and the Jewish Autonomous Region have only earmarked between 4% and 14% for these purposes. We have talked about how each region does not have to provide exactly 25%, but rather 25% should be the average. Why? Because some places are further along on this front or have already made some investments. Even 14% is understandable, 14 to 20%, but 4%! I rather doubt that the situation is so good in the regions where obstetrics and child health services require as little as 4% of the funds under their healthcare modernisation programmes.

The programmes are currently in the process of being finalised, and the relevant agreements are ready for signing. I’d like to note that the first three agreements with the Chuvash Republic and the Bryansk and Penza regions have been signed already.

The primary aim of the regional programmes is to improve the quality of medical services and to expand access to them. This is why we are building up the technical and human resources of regional medical institutions, and why we require that they provide assistance in line with the new standards. This is why we are introducing advanced technology in the healthcare system. Here I’d like to emphasise that we need a clear plan to establish a unified information system, and I ask the Ministry of Healthcare and Social Development and the Ministry of Communications and Mass Media to move this process forward.

One more issue that I want to bring to your attention, colleagues, is the poor job that is being done to inform people about the changes. Judging by the questions asked at the recent conference in Bryansk, not only local residents but sometimes even specialists and head physicians of regional hospitals are not familiar with even the broad outlines of the programmes: what will be done, which facilities are to be repaired, what equipment will be installed and where.

This process of preparing the programmes and, more importantly, implementing them must be as transparent as possible. You have to discuss these matters with medical workers and the public. As I already mentioned at the similar discussion in Moscow, I have the impression that Moscow’s medical community was directly involved in drafting the regional programme. That’s how it should be! Again, I ask the heads of regions to better inform people. You need to explain to them the essence and specific goals of the programme and tell them about the plans for each particular city or region. Ultimately, how well the programmes are executed depends on transparency. This is the way to avoid errors, to get a better sense of where the problem areas lie and to better identify priorities.

We have allocated substantial resources for the programmes and, as we have agreed, heads of the regions must personally see that these resources are used efficiently and that the plan is followed. For its part, the Ministry of Healthcare and Social Development, in tandem with the relevant federal bodies, should continuously monitor the status of these programmes. I think that the information obtained in the process should be placed on the official sites of the ministry and the regions each month. Again, each month!

Both the government and the general public need to continuously supervise the process. On this point, I’d like to return to the cost of construction. To remind you: this January the Ministry of Regional Development approved caps on the cost of major repairs and maintenance of healthcare facilities. I know that regional authorities had questions, often quite justified, regarding some construction standards. For this reason, at the meeting in the First City Hospital in Moscow, which I have mentioned, I asked that we take a careful look at this issue. And on March 4, the Ministry of Regional Development issued a new order setting repair value coefficients that take into account the specific features and standards of premises, including for the medical institutions housed in buildings deemed architectural monuments. They do exist. Clearly, when renovating medical facilities, the requirements of the bodies responsible for protecting cultural monuments shall be taken into account, and the cost will certainly be higher. Price guideposts will also be established for medical equipment.

It’s extremely important that we don’t just put new wine into old bottles when drawing up and implementing these regional programmes. Again, queues in outpatient clinics. Here are pictures for you on the screen… Last year I issued an instruction regarding this issue. Reports on the measures taken have been received. We have read them.

But what actually happens? I trust the directors will recognise their institutions on the screen. The situation shown here is, unfortunately, typical of many cities and villages.

People have to wait in queue from six or eight in the morning. Incidentally, it has nothing to do with the flu epidemic. Veterans of the Great Patriotic War, pregnant women, women with children and elderly people have to queue in the frost to enter the clinic. It was discovered that 102 patients stood in queue to Outpatient Clinic №14 in Barnaul, 86 patients queued in front of Outpatient Clinic №2 in Pskov, 80 in Yoshkar-Ola. The wait time is up three to four hours in clinics in Blagoveshchensk, Smolensk, Murmansk and Vologda.

Here are the reports on what has been done. Everything seems to be all right in the reports, but in reality things are quite different. It is clear that this is a difficult, however it is equally clear that if we don’t open our eyes and face facts we will never solve the problem. However unpleasant it may be to face, we need to know what is really going on, so that we can respond and find solutions. I know that when we focus our efforts – administrative, financial and organisational – we find solutions. This is what people have to deal with every day. We do not need reports and solutions on paper; we need to ensure that there are decent standards in medical institutions. I hope very much that these problems will also be solved in the course of the effort to modernise healthcare. The purpose of these programmes is not just to provide money for repairs and new equipment, but to improve the quality of services for the citizens of the Russian Federation.

Let’s begin our discussion. Tatyana Golikova has the floor. Ms Golikova, please.

Tatyana Golikova: Mr Prime Minister, colleagues,

Given that Mr Putin has told us in detail about the progress made on the project for perinatal centres, I would like to focus only on general issues, primarily the development of the draft healthcare modernisation programme, its adoption and implementation.

Before I get to healthcare modernisation programmes, the management of perinatal centres through these programmes and their effect on demographics and healthcare in a particular region, I’d like to say a few words on the demographic situation in the country. Please turn to the slides on demographics.

Russia’s population is currently 141.9 million. The population in rural areas hasn’t changed much since 2009. It stands at 38.2 million. The urban population has increased somewhat, as you can see on this slide. At the same time, official statistics show that the employable population is on the decline.

There are clear trends in death and birth rates – the former have been falling over the past few years (except for last year, when they grew a little because of extreme weather conditions), while birth rates have been growing steadily.

As far as mortality factors, in 2010 ischaemic heart disease and cardiovascular diseases, as well as cerebrovascular diseases, accounted for most deaths. These are followed by blastemas, tuberculosis, motor vehicle accidents and alcohol poisoning. That’s the current breakdown of mortality factors. I have given these statistics to show that the priorities of the healthcare modernisation programmes were chosen based on the demographic trends in a particular region, primarily the most prevalent diseases and mortality factors.

Here I would like to draw your attention to the demographic situation in rural areas. Birth rates here are higher than the national average, mainly due to the North Caucasus, Siberia and the Far East. And clearly, this improves the national statistics.

Since 2008, when we embarked on the National Demographic Programme, a total of 5.265 million babies were born in Russia. Most of them were born in 2010. Unfortunately, the high birth rate is accompanied by a correspondingly higher mortality rate, which cannot but influence national statistics. I’d like to note that in urban areas infant and total mortality rates are much lower than the national average. Life expectancy in rural areas is two years lower than across the country in general and 2.6 years lower than in urban areas. When we discussed healthcare modernisation programmes with regional leaders, we underscored that the main priority for rural areas should be quality and easily available medical care, because that’s the foundation of the healthcare system and it is critically important to properly set up relationships between its elements.

I’d like to remind you, Mr Prime Minister, that at the meeting in Bryansk you were asked to increase funding for healthcare in rural areas through the programmes that we are developing. We have made this slide showing mortality rates in urban and rural areas of the Penza and Bryansk regions… These regions have recently signed the agreements for healthcare modernisation programmes with the federal government. As you can see, birth rates here are lower than the national average, and mortality rates in rural areas are extremely high. This is the main indicator of a decline in population, not only in rural areas but in the regions in general.

Let’s take another example – the Chuvash Republic and Tatarstan, where we can see negative trends now. The situation was the worst in 2008, when mortality rates in rural areas started to grow unexpectedly, after a slight dip – not unexpectedly, though. There were reasons for this growth, first and foremost being the state of healthcare in rural areas.

I have put the focus on the problems in rural areas because preventive healthcare and the ground level of the healthcare system did not receive enough attention in the initial drafts of the modernisation programmes – and there have already been two versions. At our meetings with regional leaders, in particular at the final meeting on March 4, we had requested that they make up for the shortcomings in the parts of the drafts on rural healthcare – this is how we can improve demographic statistics across the country.

The programmes have three main priorities… I would like to tell how financial responsibilities have been distributed between the federal and regional budgets, according to the latest drafts of the programmes. Next slide, please.

Here we can see that the Federal Mandatory Health Insurance Fund accounts for two thirds of the funding. So it will finance two thirds of the cost of regional healthcare programmes. It is very important to use the money to be allocated as efficiently as possible, as you mentioned in your opening.

When drafting agreements with the regions, we noted that it is unlikely that they will be able to provide their share of the funding, for example, through reconstruction projects (in facilities that are 80% ready), even if we commit ourselves to providing the remaining 20%. It is absolutely necessary to have standardised engineering specifications, cost estimates and supporting documentation, developed in accordance with the decrees of the Ministry of Regional Development, as you said.

As far as planned repairs and cost estimates go, we will review and approve the lists of equipment to be purchased for each medical facility. The healthcare programmes must name those officials responsible for running particular projects through these programmes.

I would like regional authorities to remember that we specifically requested that no new facilities be built nor old ones repaired, especially if they should be dilapidated, if federal medical centres are not already being used to their maximum capacity. This does not mean that we are going to modernise federal centres using the funds to be provided through regional programmes. This slide shows that the federal government will allocate up to 20 billion roubles for federal healthcare centres across the country.

This one shows our reserve sources of funding. We need them just to guard ourselves against possible changes in the macroeconomic situation. If all goes well, these funds will be redistributed. If not, this sum will be somewhat smaller. As you can see, we expect it to stand at 21.7 billion roubles. This money will be used to stimulate the regions’ efforts on healthcare programmes.

Mr Putin, many regions have requested increased funding for these programmes. I’d like to use this occasion to tell our colleagues that it is a bit premature to make decisions on increasing the funding of programmes that have not yet been approved. First, we need to review the results of the first phase [of their implementation] and only then consider whether we should budget more funds.

I’d also like to draw your attention to frequent shortcomings in draft programmes submitted by the regions. I have specifically raised the issue of mortality rates and demographic trends in urban and rural areas.  Unfortunately, as these programmes continue to support the reconstruction and repair of hospitals and clinics, priority is not always given to those institutions that treat the most prevalent and critical diseases – in short, those institutions that would make the biggest impact on the demographic situation and on the state of healthcare in general.

Another issue that we raised during our meetings with regional leaders was the third priority of the healthcare reform – the need to improve the quality of healthcare, which you also mentioned in your opening remarks. In order to accomplish this task, we must raise wages in the industry. Many programmes call for the extensive adoption of modern technology and a very significant pay raise – up to 160,000 roubles for doctors – but only at a handful of clinics or hospitals, while the rest are left on the margin.

The next issue I’d like to focus on is the primary goal of these programmes. We are not working just to repair, reconstruct, or modernise something, but to improve the quality and availability of healthcare. I have to admit that most target figures, which are the main measure of these programmes’ effectiveness, looked very poor.

On the one hand, among these programmes, it is as if the concrete agendas for such national projects had gone unnoticed, although substantial funds had been invested for the improvement of healthcare, whereas others seemed to produce positive results. And in programmes scheduled through 2013, indicators of progress simply stagnated – and that’s how some achievements of 2010 ground to a halt. Money was invested, and nothing happened. This was a clear signal for regions to also pay attention to what was going on.

And as for medical staffs... Now every programme requires that those specialists who are specifically needed in a given region are retrained.

You have already spoken about obstetrics services and its 25% share of the funding towards modernising healthcare. I would like to append to this issue the first item on today’s agenda, which regards perinatal centres.

Healthcare modernisation envisaged a three-pronged arrangement of obstetric aid. That was the point of this entire work. It is of principled importance that perinatal centres are at the forefront of medicine. But then there are also rural maternity wards and first aid stations. They, too, deserve attention.

I repeat that I called your attention to rural healthcare and rural mortality rates because rural healthcare accounts for a great part of our entire healthcare network. And yet, maternity wards intended for women with no abnormal health problems need our attention and equipment, at least at the primary level, even though we have new perinatal centres. This point is of critical importance.

I am saying all of this because of alarming statistics. Women with grave health problems comprise 59% of patients at the Tver regional perinatal centre, 58% in Kemerovo and 42% in Kirov. Rural women account for an impressive 80.5% at the Kursk regional perinatal centre.

We have recently been to Tver and its new perinatal centre. A bit later, I visited an ordinary municipal hospital. Its maternity ward is in an appalling state, though the hospital is involved in the programme for healthcare modernisation. The birth rate in that town – I don’t want to mention its name – is an even 220, above the national average. However, an average 80 out of those 220 mothers deliver at the Tver perinatal centre while the municipal maternity ward isn’t working to full capacity. Even healthy women prefer to go to the centre because of substandard obstetric aid in their native city. So I call on the Russian regions to address this problem. A maternity ward can cope with healthy patients, while the perinatal centres we saw today and have seen before are meant for mothers and babies with health problems.

I also want the regions to see that the goals of their local healthcare modernisation programmes and of the national reform overlap on many points. I don’t intend to enumerate them here – everyone knows them well enough. That was one of the drawbacks we saw in the healthcare modernisation programmes.

I would like to say a few words about the programmes that provide government guarantees on free healthcare. At present, these programmes are the pivot of healthcare funding in all Russian regions, especially since the new law was endorsed. We have allowed for a two-year transition period before mandatory health insurance enters into full force in 2013. Many regions should pay close attention to the matter.

Territorial programme funding will grow by 25% by next year on average, as compared to 2009, in terms of costs. Regrettably, expenditures will grow by only by 3% to 4% in, let say, the Altai Territory and Tuva, which means that all efforts on healthcare modernisation programmes will be futile by 2013.

There is another aspect to this matter. We must gradually increase the share of mandatory insurance in financing healthcare. A majority of programmes reflect this trend. The share is increasing from 51% to 54% even in the five areas [of medical care] presently funded by the mandatory health insurance system. However, the share of mandatory insurance is below the national average and does not even reach 40% in the Tula, Magadan, and Sakhalin regions and the Khanty-Mansi and Yamal-Nenets autonomous areas.

Regional governors should realise that if this trend persists, we will be unable to shift to mandatory health insurance in 2013. In particular, some expenditures, including salaries in the mandatory insurance system, will become unaffordable.

Grants for the insurance of the unemployed are also provided by the programme of state guarantees. An overwhelming majority of regions are planning to increase these grants. However, the Vladimir, Voronezh, Moscow, Orel, Tula, Kurgan, and Tyumen regions; the republics of Dagestan, North Ossetia-Alania, Mari El and Buryatia; and the Altai and Primorye territories have presented very small grants. Here, we are facing a problem similar to what I have just mentioned.

There is another problem: a lack of attention to meeting federal standards. This concerns, for instance, outpatient visits in the Leningrad Region, Chechnya, and Ingushetia. Clinics are visited very rarely there – which means that hospitals are overloaded, while primary institutions do not run properly.

There is another question: labour remuneration. It is an essential factor in all fields that we are discussing today. Salaries are a critical topic, whether we regard them from the point of view of healthcare modernisation or doctors’ attitudes towards their jobs. We have relevant the statistics. According to our calculations, these are national average figures. You see here the data before 2009, which the Ministry of Regional Development announced in regional reports and forecasts for this and next year, derived from regional statistics.

Mr Prime Minister, as for the regions with which we have signed this agreement, I present the documents of the Penza Region programme. It concerns Penza alone. Now, the Penza and Bryansk regions…

Vladimir Putin: How many programmes have you approved – 51 or 41?

Tatyana Golikova: We have analysed them all…

Vladimir Putin: But how many have you approved?

Tatyana Golikova: …we have signed agreements with only three.

Agreements for the city of Moscow, the republics of Khakassia and Tatarstan, and the Saratov, Samara, and Tomsk regions are almost ready, and will be signed within days. However, 32 regions did not even submit adjusted drafts subsequent to the government meetings. We have informed the government, so I there is no point in enumerating them. I’ll do so if you like.

Vladimir Putin: Do, please.

Tatyana Golikova: Alright. As of March 10, the drafts have not arrived from the Voronezh, Ivanovo, Kaluga, Ryazan, Tver, Tula and Arkhangelsk regions, the Nenets Autonomous Area, the Leningrad, Novgorod and Pskov regions, the Republic of Adygea, the Krasnodar Territory, the Astrakhan Region, the republics of Dagestan, Ingushetia, Kabardino-Balkaria, North Ossetia, Chechnya and Udmurtia, the Perm Territory, the Nizhny Novgorod and Sverdlovsk regions, the Khanty-Mansi Autonomous Area, the Kemerovo Region, the Republic of Sakha (Yakutia), the Kamchatka, Khabarovsk and Primorye territories, and the Sakhalin and Jewish regions.

Vladimir Putin: That’s odd – it’s the 11th of March now. If I could, I’d shout: “What do you think you are doing? You’ll have no time for the programmes this year, and you won’t get the money. You’ll botch up the work unless you have updated and submitted your programmes. So when will you? The ministries will also take some time considering them and they will also find fault with you. After all, you’re in your own interest to get large federal grants for the solution of critical healthcare problems. We are helping you, but it’s your own responsibility!”

When are you expecting these programmes?

Tatyana Golikova: All the deadlines have passed. Mr Zhukov appointed them at the previous meeting, and we expected them before March 10, but none have come yet.

Vladimir Putin: So none arrived by March 10? You’ll all gather in Moscow next week, each clutching a programme in his hands... Ms Golikova, go on please.

Tatyana Golikova: Last but not least as far as salaries are concerned, the Penza and Bryansk regions and Chuvashia increased salaries for every institution enrolled in the programme, as I have said. This slide represents future wage raises in the Penza and Bryansk regions.

Please notice the negligible previous earnings in the Bryansk Region. So we expect a 70% raise there, compared to the 31% national average, due to higher healthcare standards.

Significantly, this concerns outpatient clinics, among others. Specialists’ salaries will increase in such clinics, due to a federal target allocation of roughly 60.8 billion roubles within two years. So we expect the regions to reciprocate.

I have quoted the statistics of the Penza Region as an example because of their feedback – investments are coming not only from the federal treasury but also from the region itself, and we think it is already efficient enough in those fields which the programme of healthcare modernisation concerns.

I would like to add in conclusion that, according to figures submitted by 57 regions, average wages will increase 4,901 roubles a month, with 7,151 roubles for specialists and 3,460 roubles for doctors’ assistants and nurses in outpatient clinics. This is the first practical benefit of modernisation efforts that we have heard reported.

Vladimir Putin: Good. Mr Zhukov, please contact all your colleagues by phone, as I have instructed. If you fail to arrange proper work on these programmes in time, come yourself, drafts in hand, and gather a meeting. I’ll surely attend it.

* * *

Vladimir Putin’s concluding remarks:

Ladies and gentlemen,

I’ll keep my closing remarks brief. I just want to say a few words about the importance of the work we are doing.

We have many routine problems, and it is absolutely unacceptable to treat them as if they are insignificant. The lives and health of Russian citizens and, ultimately, the future of our country depend on these issues. So I ask you once again to monitor each stage of the job we are starting. Your comments and proposals will be included in the final document of this meeting.

I expect everyone to work diligently, and it’s my hope that we will review our results at each stage. Thank you.

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