Vladimir Putin's address:

Good afternoon, friends. Let me first thank you for inviting me to take part in your forum.

We have been discussing issues of national healthcare development at the federal level and on almost all federal TV channels for at least half a year already. However, in my everyday communication with friends, many of whom are healthcare workers, it has become clear that the medical community itself is only faintly aware of this. That is why it is necessary to hold such a meeting with experts from all regions of the Russian Federation and to allow medical workers to be better informed of our plans in healthcare directly by our experts and the Ministry of Healthcare and Social Development. And as for our experts and the authorities, they can listen to you and correct the current plans in time, if necessary.

I would like to cite Solzhenitsyn, who called the preservation of the nation the key priority of any state. There is no doubt that this is our most important goal. We have been gradually increasing our investments in the social sphere, education and healthcare. Since 2006, as you know, we have also been implementing national projects, each of which has a clear demographic component.

We have managed to handle the most acute issues, indeed. First of all, we have curtailed the destructive tendencies that posed a threat to the state's existence and development and that were leading us to real catastrophe if left unaddressed. Despite our numerous efforts, the country's population decreased by 500,000: these are serious figures. However, we should remember that Russia lost about 700,000–800,000 each year in the 1990s, and sometimes the figures came to a million.

At present, we have stepped back from this point of crisis – this precipice. There is much work yet to be done, but nevertheless, we have proven that demographic problems can be solved however complicated they might seem. Since 2005, the life expectancy in our country has grown by almost four years, with a 19% increase in the birth rate and a death rate that has dropped over 11%. There is also a considerable (one third) decrease in infant mortality. Life expectancy in Russia grew from 65.3 to 68.9 and stood at almost 69 years in the period of 2005–2010.

There is no doubt that the economy and economic progress are the basis of social wellbeing. However, we cannot accept an approach to the achievement of economic prosperity at the expense of concurrent social initiatives. It is my strong conviction that we should both develop the economy and support the social sphere, keeping them in harmony to a certain degree.

We will continue investing our resources in human and family wellbeing, the creation of conditions for a full life, and the self-actualisation of our citizens through housing programmes, education, and the protection of motherhood and childhood. The government certainly doesn't intend to give up these plans. However, it was extremely difficult to solve these problems – especially under the conditions of the world financial crisis. It was hard to make the decision to allocate such considerable funding for the further development of education, with regard to a great number of uncertainties in the world and in national economies.

As I have already mentioned, I believe that it is possible to ensure both economic growth and the improvement of social standards. In due time, there were many of those who doubted our decision on the Health national project in 2005. Many experts questioned whether the efforts were necessary at all. They said: "It is necessary to follow the plan without any extraordinary solutions or pouring in money. As a rule, extraordinary actions do not achieve their intended results, but the money will be drained away and that's that." However, subsequent events have proved that we made the right decision at that time.

We can now review the results we have achieved due to the joint work of the federal and regional authorities and those present, including your colleagues – the medical community.

There have been fewer citizens dying of tuberculosis and traffic accidents. Mortality from vascular system diseases and cancer has begun falling.

Mortality from tuberculosis dropped by 16.2% between 2008 and 2010, when a number of preventive measures and treatments were put in place. And the measures on the establishment of a system for delivering medical care to the sites of traffic accidents helped bring down the related death rate by 20% during the same period. It is a considerable achievement.

Mortality from vascular diseases has also dropped. The figures are much more modest, at only 4.5%, but they stand for the lives of real people.

About 10,000 medical institutions have received up-to-date medical equipment and ambulance services have received over 13,000 new, well-equipped cars. The period of waiting for diagnostic tests in outpatient clinics has become three times shorter; the arrival time of emergency personnel has been cut almost in half.

We have paid special attention to pregnant women and newborns. About eight million women and four million babies received medical care as part of the maternity certificate programme. It should be noted that an efficient and competitive environment has been already established in this healthcare sector: a woman has the right to choose the maternity clinic that will provide her with the most comfortable conditions for her care.

In a way, these initiatives have influenced the income level of medical workers as well. The average salary of the doctors who participate in the maternity certificate system has increased by 20%. In addition, 11 new perinatal centres equipped with modern facilities were opened in 2010. Another 12 perinatal centres will be commissioned by the end of the year. I believe that those of you who visited these centres were convinced of the appropriateness of the programme. As for me, I have a feeling of pride when I see the people who work there and the conditions under which they work. This is quite a different level of care that at times even leaves our European neighbours behind.

We will continue increasing the affordability of high technology in medical care. Over one million patients have received high-tech care over the last five years.

That is, of course, significantly more than in previous years, but it is still not enough. When I think of those who were denied assistance, my heart bleeds because this is about people’s fates and lives.

Even so, seven high-tech medical centres are already working; they are located in Penza, Cheboksary, Astrakhan, Khabarovsk, Krasnoyarsk, Chelyabinsk and Tyumen. Five more such centres are to be opened this year.

On the whole, healthcare services received an extra 780 billion roubles under the Healthcare national project. I would like to stress that this is over and above current funding, which has also been increasing, not dropping. We will continue implementing all measures included under the national project: the federal budget will disburse 788.7 billion for these purposes before 2013.

Let me emphasise that our collective work on the national project has laid the groundwork for a sweeping modernisation of Russian healthcare. But we are well aware that many problems still remain and that medicine still calls for massive financial support.

Last year, when the country was just emerging from the crisis, we also heard a lot of arguments about our further plans for the development of the healthcare service. We decided to launch a new social project in the sphere and start large-scale healthcare modernisation projects in the Russian regions. To understand the inherent logic and motives of our actions, one simply has to face reality, face the truth.

We have spoken about some positive trends in the healthcare system, and, on the whole, we have something to show for it. Yet the average lifespan in our country is 8-10 years less than in neighbouring (i.e., European) countries. The mortality rates of the diseases that I have mentioned – for example, cardiovascular diseases – are 4 or 5 times higher than in Western Europe, and infant mortality is 1.5 to 2 times higher.

More than 30% of Russian hospitals have no hot water, more than 8% have no running water, 9% have no sewerage. A quarter of all the medical facilities in the Russian Federation are in need of overhaul. As for the technical conditions and equipment, more than 60% of X-ray installations, for example, and nearly half of ultrasound and ECG test equipment have reached the end of their service lives.

The salaries of many medical workers are barely above the subsistence minimum. Such an attitude towards doctors leads to poor quality medical services, that much is obvious. It is, however, equally obvious that we cannot delay a change to the healthcare system or put it on hold by citing the crisis and other temporary difficulties.

Now, as then, I am 100% sure that we made the right decision in creating a financial basis for the regional programmes. Over the next two years, we are now able to continue to invest in the healthcare system – that is, over and above current financing to the substantial tune of 460 billion roubles – in order to reinvigorate the network of medical institutions in Russian towns and villages, which I was talking about just a minute ago. This means essentially investing in human health, upgrading the quality of medical care and making it more accessible, and, of course, supporting the people who every day perform the noble mission of helping the sick.

Major changes are to take place in our healthcare system over the next two years. The important thing is that they become real to the citizens of Russia who should be feeling these positive changes.

Dear friends,

Permit me to dwell on priority issues on which all levels of government and the medical community should be focusing their common efforts.

Under the regional modernisation programmes, we must first of all strengthen the primary level of care – that is, district and city hospitals and polyclinics, rural nursing and midwife centres, and outpatient medical centres, which deliver 80% of medical assistance to the population.

Over the next two years, more than 40% of federal and municipal medical facilities will be repaired, the construction of all the projects in progress will be completed (for your reference, about 8,000 of the 18,000 federal and municipal healthcare facilities are to be repaired). The healthcare system will get more than 100,000 units of modern medical equipment. This range is very broad, covering about 1,400 models and specimens. Over the next two years, 100 billion roubles from the federal budget will be used for these purposes. That is about half of the current annual market of medical technology.

We must build a clear, coherent and transparent process for procuring equipment and repairing buildings, so as to rule out any speculation, fly-by-night firms, and any number of other corrupt practices. Corresponding changes will be made in the legislation. It is important not only to organise uninterrupted supplies and the installation of equipment but also, of course, to train medical personnel to use it, to deliver high quality, and to preserve the equipment that is acquired.

We decided at the congress of the Independent Trade Union Federation in January that the relevant provisions should be included in collective employment contracts. Provisions must be made for internships and residencies at leading centres and clinics, and a concerted effort should be made to continue developing the retraining system.

And one more thing. When we speak about medical equipment, we usually mean sophisticated equipment such as tomographs, ultrasound scanners, automatic micro-analysers, and so on. But it is also very important that every doctor have portable instruments, from compact ultrasounds and ECG sets to elementary blood pressure gauges, all of which makes diagnosis more accurate and improves the quality of medical services and the quality of treatment. A doctor working in remote areas where he needs to make quick decisions and act independently must be particularly well-equipped.

You remember what a shortage of primary-level specialists our healthcare system experienced several years ago. In 2005, precinct services had only 60% of the staff they needed, and in some regions, they had less than fifty percent. Under the Healthcare national project, we have preserved, or rather, revived that level of healthcare and brought in new doctors and mid-level personnel. Salaries were raised for more than 300,000 primary-level medical workers, and more than 50,000 precinct doctors have taken retraining courses and upgraded their knowledge. The percentage of part-time medical workers dropped from 1.6% in 2005 to 1.1% in 2010.

Of course, we need to move forward, above all in changing the principles according to which district doctors work. At present, they spend as much as half of their working time filling out various certificates, referrals, and prescriptions – that is, things that are only indirectly related to the process of treatment and diagnosis. As some of my acquaintances in the medical community joke: a doctor remembers everything about his patient, and he writes the papers for the prosecutor. That situation cannot be tolerated and it must be rectified.

The eternal problem of our healthcare system must be solved. Doctors and mid-level medical personnel should be relieved of the chore of filling out often meaningless paperwork, while truly necessary information should be converted to an electronic format, including case histories. The Ministry of Healthcare and Social Development must quickly finalise the procedure for delivering primary medical assistance and determine the duties of precinct doctors and nurses. Ms Golikova (addressing the Minister of Healthcare and Social Development), in your opinion, how much time will it take to develop and introduce that system?

Tatyana Golikova: We have practically everything ready. We spoke about it in part one. We are waiting for the adoption of the law “On the Basic Principles of Legislation in Healthcare,” which will enable us to issue it as a regulatory act on behalf of the ministry.

Vladimir Putin:  When do you expect it to be passed by the Duma?

Tatyana Golikova: The draft law is finished and is pending before the government. As soon as the government approves it, it will go to the Duma…

Vladimir Putin: Let us put it on the agenda of the next government meeting.

Tatyana Golikova: Very well.

Vladimir Putin: Next. In making primary care more efficient and raising the qualifications of precinct doctors, the quality of their services will undoubtedly go a long way towards improving preventative treatment and the early detection of diseases. Medical workers themselves stand to gain from it: considering the current mechanism for funding medical care, in which the money follows the patient, a large portion of the money will remain at the primary care level, which should increase the pay of precinct doctors and nurses.

A few words about rural healthcare. It was agreed during the recent congress of the Association of Peasants’ (Private) Farms in Tambov that more attention should be paid to developing the rural health service, especially considering that the situation there, unfortunately, is deteriorating rather than improving.

That is an alarming and intolerable trend, and it should be reversed. In the coming two years we should reorganise at least 2,000 primary medical and obstetric centres and open 300 more, in addition to organising more than 1,000 general practitioner offices in rural areas.

I have to say that there has been some positive experience of rural precinct services being switched to the general practitioner principle, for example, in the Astrakhan and Penza regions, in the Republic of Chuvashia, and in Tatarstan, where medical assistance has been brought as close as possible to the rural population.

And needless to say, we must create conditions in which specialists, especially young graduates, have an incentive to work in the rural healthcare system. If you look at what is happening in some regions – for example, in Smolensk, just 150 km away from Moscow – in the city itself, there are 50 doctors per 10,000 people, but in the surrounding rural communities, that figure drops to 15.

As part of these modernisation programmes, modern standards of medical treatment must be introduced, and the system of state guarantees must be effective. Regardless of where a person lives, he or she must have access to free and high-quality medical service.

The new law “On Medical Insurance” should kick in. It will give citizens the right to chose their own doctors, medical institutions, and insurance companies and use those facilities where they can get the best medical treatment.

We noted what massive resources were needed to modernise healthcare, and we have spoken about the supply of modern equipment and the repair of premises and buildings. But we will never achieve success if we fail to change the attitudes of medical workers about themselves and their work.

The Russian philosopher Ivan Ilyin once asked his doctor for the secret of his skill. He replied that it was the love of his patient, without which there is no first mover of the heart or the soul.

Unfortunately, let's face it, that first mover is sometimes not performing well in our healthcare services. Many people visit the government site and the public reception offices to complain about medical workers who are rude, unethical, and occasionally extort money. I hate to have to say it, but this is a fact. It is better to say it aloud and then consider how to go about solving it. Ultimately, what is taking place at this or that institution and what relations exist between the people who come to the institution and its staff depends on us. Many problems are not being solved not because of a lack of money but because nobody addresses them.

Take the much-maligned queues. Some people have to spend days in stuffy corridors, as was mentioned, incidentally, at a recent meeting in Ryazan. Those who had ears listened to this plea and took the necessary measures to mend the situation. For example, the cancer polyclinic in the Chelyabinsk Region promptly made changes. At once. The reception desk started to open at 7.30 am, they opened five additional windows for making appointments with specialists, and increased the number of offices for doctors at the expense of administrative space. But some regions have not reacted to the call and are apparently waiting for somebody from the top to conduct a post mortem for them.

I believe that we need to put in place a clear-cut, understandable, and effective system of medical quality assurance. People often complain about derelictions on the part of medical personnel who sometimes do harm to the patient’s health.

I suggest that we annually publish the ratings of medical institutions and insurance companies taking into account the opinion of patients. We should start with state healthcare institutions, major insurance companies, and private healthcare organisations.

I think that information on the real state of affairs at medical institutions and their reactions to citizens’ complaints must be absolutely open. It is absolutely inadmissible both for patients and the medical community to conceal unseemly occurrences and cover mistakes. I am sure that the more complete and accurate the information is, the faster the process of positive change in the healthcare system will proceed.

Dear friends,

We have spoken about the attitude of doctors to their patients and the quality of their work. Of course, complaints should evince a reaction. But medical workers deserve to be heard and to be understood. Many doctors and nurses are quite candid about it; when you earn pittance, it is hard to smile and be cheerful.

It is no secret that after getting their degrees, doctors come to work at a hospital or polyclinic at a salary of 5,000-7,000 roubles a month and have to hold several jobs, do night shifts, and sometimes work two shifts in a row in order to feed their families.

It is obvious that medical professionals should receive a respectable salary. The regional programmes should see to it, too. The adoption of new standards specifying the amount of remuneration for certain types of healthcare services provided by a doctor, a paramedic or a nurse would be very instrumental in resolving this issue. A medical staff’s salary will be higher than it is now. I believe everyone here understands the issue. With stomach surgery, for example, labour costs account for 5,600 roubles of the total cost. The new standard will raise this number to 12,500 roubles, and a healthcare professionals’ payroll will be up at least 30%-35% two years from now. Certainly, these are only first steps and they are obviously insufficient. We should think about further action.

I would also like to talk about the contributions to the mandatory health insurance fund. We have increased the amount of these contributions by two percent. Beginning in 2013, these contributions will be used in full to finance medical assistance, including healthcare professionals’ salaries, which should also come as a tangible addition to their earnings.

Let me remind you that a reform of state-run agencies will give medical executives new opportunities to provide a financial motivation to the best specialists. By all means, we will continue to adjust public sector employee’ wages for inflation. As you are probably aware, the law (already adopted) stipulates a 6.5-percent increase in wages beginning this June. In autumn, we will review this percentage based on economic and social developments. I talked about this at a United Russia function.

However, a healthcare workers’ financial status and living conditions also depend to a great extent on the regional authorities. Some of Russia’s regions manage to find resources and build strong teams of healthcare professionals without any windfall revenue going their way, while others don’t deal with the issue at all.  

Let me cite a positive example. Some in-demand medical specialists in the Penza Region get an additional 10,000 roubles a month from the regional authorities, and surgery nurses get an additional 5,000 roubles added to their regular monthly salaries from the regional budget. The regional authorities have launched their own programme for specialist recruiting and retaining. A doctor or a recent medical school graduate receives a relocation allowance if he comes to work in the Penza Region. Three years’ worth of this allowance amounts to 375,000 roubles, which can be used toward paying off a mortgage. The first batch of this allowance is 150,000 roubles; another 50,000 roubles are paid at the end of the first year, 75,000 roubles at the end of the second year, and 100,000 roubles at the end of the third year of employment.  

According to the experts, over 70,000 young doctors across Russia need better housing conditions. Only 2,000 to 2,500 of them manage to solve this issue effectively every year. We should all focus on this problem and address it, using all the positive experience accumulated in the regions. For example, the Khabarovsk Territory’s municipal authorities provide housing to the medical university graduates who enrolled under the federal programme, and this is the right thing to do.

Let me reiterate, a great deal depends on the willingness of the regional authorities to be effectively involved in fixing the issues faced by the healthcare industry. We will always support such initiatives. To be specific, the government is in the process of establishing an incentive fund of 30 billion roubles, which will be used to provide funding to the constituent entities that are actively developing the healthcare industry. The Penza Region and the Khabarovsk Territory have very good chances of getting some of these resources. We will also support those who work to solve this problem.

I’d also like to bring up a few more sensitive issues. There is a problem directly affecting the salaries of healthcare personnel. I’m talking about an inflated staff of healthcare executives. The amount of the lowest salary in the industry to a great extent depends on the number of managers and directors. For your information, there were 28,000 medical superintendents and deputies for clinical care in Russia in 2010. Quite a few medical superintendents have up to 10 deputies on top of aides, personal assistants, you name it.  

Some time ago, the government decided to limit the number of deputy ministers to two. But then the deputies started springing up like mushrooms. There was no way to hold them in check. Deputy ministers are now everywhere, wherever you look… The same thing is now happening with medical superintendents. I can agree to three, four or even five deputy defence ministers, but eight to ten deputy medical superintendents is definitely overkill.

At the same time we witness an unjustifiably large gap between the salaries of a medical institution’s directors and its medical specialists. In some regions, it’s a five- to seven-fold difference. The medical executives’ salaries alone account for over 15 billion roubles annually.

I believe that we have way too many healthcare officials. We need to bring this number into compliance with the reasonable and real needs of the industry. Practicing doctors, paramedics and nurses constitute the mainstay of the healthcare industry, and we should base our payroll decisions on this understanding.

We can’t ask medical workers to be efficient and effective without giving them decent living and labour conditions first. People who are in charge of these things often forget to provide hot meals for those on 24-hour continuous duty at a hospital, shower facilities for medical personnel involved in surgery, or even clean whites, for that matter.

Certain medical facilities have gone as far as suggesting that the doctors should buy uniforms with their own money. Looks like someone has no economic interest in placing orders for such “equipment” if you will.

The upshot? All these seemingly minor issues coupled with low salaries and poor housing conditions form a huge problem that damages the credibility and respect associated with the medical profession. I’m asking healthcare executives and public associations to focus on labour conditions during the implementation of regional programmes.

The interns, or medical college graduates, deserve a different discussion. There are many issues here, which need to be sorted out. Today, an internship can only be taken at 55 medical academies and universities across Russia. What do the interns do, if they live in a place where there are no such schools?

So we end up with a medical school graduate who can’t go back to his home town, such as Magadan or some place in Kamchatka and find a job, but instead has to do an internship at medical schools in Vladivostok or Khabarovsk, if we talk about such a problem-ridden area as the Russian Far East. An internship is enough time for many to start a family and find permanent employment with a hospital or some other employer. After a year these young people can loose their motivation to move back home, which is quite understandable.

On top of that, an intern is paid only a maintenance allowance in the amount of 2,700 roubles a month. As a result, we are pushing an adult with a higher education to look for any additional job just to pay the bills, instead of motivating such a person to pursue his or her professional career.

I’m asking the Ministry of Public Health and Social Development, the Education and Science Ministry, and the Finance Ministry to settle these issues, including internship regulations and intern allowances, in the near future. Please come up with some proposals.

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To conclude, I’d like to say that accessibility of high-quality health services, doctors’ and nurses’ living and labour conditions, and the way they do their jobs all have a lot to do with the lives of specific patients and their families, and with Russia’s future in general. The price of the purported reforms is very high, but the hopes and expectations of millions of Russian people have an even higher price. Our common goal is to live up to these expectations and the trust of the Russian people. I think we are in a position to achieve this goal. Thank you for your attention.

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Vladimir Putin comments on a speech by Leonid Roshal, Director of the Moscow Emergency Child Surgery and Traumatology Research Institute and President of the National Medical Chamber

 Vladimir Putin: Just to be clear, it was me who asked Leonid Roshal to speak today knowing in advance that his speech would be controversial, topical in some ways, professional in some ways, and, I hope Mr Roshal will forgive my saying so, in some ways naïve. However, this naiveté comes from the heart, from the wish to improve things, which is really what matters.

Several remarks about self-regulating organizations. Mr Roshal came to the Government House recently, and we sat down and talked about it. Overall I share his approach not only to self-regulating organizations in the healthcare system, but in general: we should gradually hand over some of the government’s functions to self-regulating organizations.

I would like to tell all of you, including Leonid Mikhailovich, that in Germany a similar chamber has been used for 130 years. It only ceased functioning under Hitler. For 130 years. You know that they have a certain culture and a legal framework, of which I’ll speak in a moment.

In the construction industry we have handed over a significant portion, not all, but a significant portion, of the functions to self-regulating organizations. The vast majority of the country’s construction companies that had been advocating this in the first place are now saying, bring back licensing, it’s become impossible to work. These self-regulating organistions have assumed these functions and they are not always capable of fulfilling their responsibilities – I am not saying that this is a universal situation, but still. Those who dominate among these organizations are beginning to make things difficult for the others: shove them aside, withhold some things. We had a meeting recently and I am going to have another meeting with the construction sector, I want to listen to them more attentively because it’s an important part of our activities and they have been asking us to restore the previous process. Apparently it was easier to operate then, they say.

In general, Leonid Mikhailovich is right: we should move in that direction, but we should be cautious.

Leonid Roshal: Unlike the builders, who have grabbed everything, we are taking over a very small part…

Vladimir Putin: Yes, yes.

Leonid Roshal: … the professional side.

Vladimir Putin: No, in construction they also took over only the professional side. They do not do gynecology there, believe me, just like you won’t take over construction. One simply needs to proceed step by step. But this is generally the right approach. Now with respect to the process, of course the concept should be planned before any laws are amended. But as far as I know the concept was adopted last year. Perhaps it needs to be reviewed.

Leonid Roshal: Where is the concept? There is no concept. It hasn’t been published.

Vladimir Putin: There is in fact a concept. It has been adopted and passed. But this brings up another problem. If even Mr Rochal doesn’t know that the concept exists, it means that it has not been discussed enough  in the professional community.

And this law… For example, we’ve seen some discrepancies crop up in the law on education. We adjusted it which initiated a discussion on the internet by professionals and those who are simply interested in education. It should be the same with the construction industry. The internet allows many people to be involved including those with strong professional backgrounds. So we should do this. If many of those present do not know about the concept it should be discussed again, reviewed, adjusted and adopted as the basis for a future law on healthcare. I absolutely agree with that.

I also agree that in some areas of activity… You know, many criticize Law 94, and rightly so, and more recently there have been some noises about Executive Order 601 issued by the Ministry of Economic Development. I don’t know a lot about it and I don’t know why they put cotton or whatever in the same category as tomography machines or what their rationale was… As Chernomyrdin (Viktor Chernomyrdin, one-time Prime Minister) said in his time, “we tried our best, you know the rest.” But we will set things right. We can handle that.

Now about professionals at the Health Ministry. In the 1990s there were only doctors at the Health Ministry, and yet the situation was worse than today. It is true that organisational experts – economists, accountants—are needed. There should be people who know some things, but not other things, and still have a good grasp of healthcare matters. But an organizer is not a practicing surgeon. We’ve had some people, including some of my friends, who were ministers and took time off once or twice a week to manage surgical operations. I don’t know if combining such things is right; one member of the President’s Administration still goes to sing at the Mariinsky Theatre in St Petersburg…

Leonid Roshal: Vladimir Vladimirovich, there is a minister sitting to your left who combined…

Vladimir Putin: I know, I know him. 

Leonid Roshal: On your left, he was a fine minister and he combined everything.

Vladimir Putin: All right. There have been people like that. There are both kinds, but that’s not obligatory... The surgeon or whoever does not have to be practicing, that is not obligatory although of course one must understand the sector in which one works. But a manager has to be a good businessperson or financier above all else, he must understand where the money goes and how it is spent.

Incidentally, I fully agree with Mr Roshal, and we have discussed it with him and he just repeated it: if one proceeds carefully, a large part of the resources allocated for the health service can be saved and used to introduce all these programmes… Why reinvent the wheel again and again only to earn some money and land some orders that are quite unnecessary? A lot can and must be changed there.

Now, our people, wherever they live have the right to and must have the opportunity to receive quality treatment, regardless of where they live. That applies not only to medical treatment, but to education, to  many aspects of life and to social needs. However, we must be realistic. This is impossible in some places. One should certainly work towards that goal. Everything must be done to make it happen everywhere eventually.

That is in fact what we are trying to do. How many subsidized regions do we have? More than we have contributor regions. Money is collected and then redistributed. More than 1 trillion roubles are redistributed. As a rule, the regional leadership determines the spending priorities. One may of course correct them, one can start telling the regions what to do and say: we give you so much and you have to spend no less than a certain percent on healthcare, so much, and not less on education and so on. That is an option.

But there is another approach, one that delegates responsibility to every level, and people should be aware of their own responsibility, and anyway it is impossible for Moscow to tell everyone in every town or village what to do. Take healthcare: we have determined that 25% of the total funding of 460 billion roubles should go to finance the modernisation programme – for children. But that is an approximate target. Why? Because some things have already been done in some regions, towns and villages and they do not have to spend 25% of the total sum on that. In some other places nothing has been done and there they need to spend 30% and even that would not be enough. It is difficult to dictate decisions from Moscow for every activity. That too can lead to irrational spending – that’s the crux of the matter. It’s not that somebody is against it, but there are doubts that it will work.

Finally, the most important thing, which closet to take the money from. Mr Roshal is right, even though he is constantly criticizing the Health Ministry, which I actually can appreciate - I wish there were more people in other sectors who, calmly and phlegmatically, keep pecking away at problem spots - perhaps we would then be able to bring more executive orders like order 601 to light and amend them as needed.

Of course, the country allocates only 3.9% of GDP to the health service. Obviously, that is too little. We will soon be able to raise that figure to 5%. That would still not be enough. But then we only have 100%. Five percent for healthcare, and a similar amount for education, and remember that 10% of the GDP goes to pay pensions. And the total amount is 100%. The question is how to slice the cake. And you have to bear in mind the defence industry and defence in general. There are many things to consider. And you have to finance everything, it’s about getting your priorities right. Of course, the health of the nation, the preservation of the nation is the number one priority. There isn’t much more I can tell Mr Roshal about this, but again, we will move in that direction. We are determined to. What are the financing sources? Let us ask this question plainly, what are the sources for increasing the funding? It is either having the public share the cost, but Mr Roshal is right, we should seek to preserve as much as we can of what is written in our constitution, and we cannot act otherwise, to preserve free healthcare. Another option is direct financing from the budget. But, as I said, there are constraints because the money has to be divided between many sectors. The third option is to increase insurance premiums. This year we raised it to 34%. You have seen the reaction of the business community. In order to implement the plan proposed by Mr Roshal we should not cut the 34% premium, but rather increase it to 44%. It is about balancing the interests of society and about not putting the cart before the horse. How should we balance spending, where should we get the money, how should we proceed during a crisis and as the crisis ends? Anyway, we will see what can be done to reduce and not increase insurance premiums. There is a logic to this too, but the options for increasing the financing are limited: you cannot just start the printing press and print more money and give it to the health service. Inflation would kick in immediately and all our efforts would be reduced to zero. Just zero. No law would help us, neither Law 94, nor law 95, whatever it may be, because everything will be ten times more expensive.

A modern economy has its own laws and society has to pay a dear price for ignoring these laws. But the purpose of our meeting today is to discuss all these problems frankly. I wanted to get our point across to the medical community; I wanted you to hear this discussion and to join it.

Thank you very much.  

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Vladimir Putin’s concluding remarks:

I would like to make two remarks concerning what Mr Dorofeyev (the head doctor of Novosibirsk Clinic No. 1) said. He focused on the worries that district health services will be eliminated. Nothing of the kind! We have never intended to do such a thing – just look at the draft documents.

I would like to draw your attention to what lawyers know as a legal technicality – the words and phrases the authors of a law use to bring their idea down to the future executor. The wording of this article should certainly be more precise and explicit. The way it is now, the law stipulates patients’ right of the so-called controlled choice – that is, from among the alternatives offered by the district practitioners.

This is more proof that we were right to gather here in order to hear each other out and make relevant adjustments to our decisions in good time. These decisions must be fundamental and remain relevant for many years ahead. Meanwhile, as you said, the limit is five minutes for some specialists and two minutes for others. All this should be checked, and changed whenever possible.

As for the Year of the Doctor and the Year of the Teacher, we had the Year of the Teacher in 2010, but that programme did not include any grants. Now, we are awarding healthcare grants even if we have no Year of the Doctor. Which do you like best?

As for education, we are starting to address the problem only now. We will be planning a relevant programme, and it might be launched around September 1. The primary costs associated with it will start next year, though some things will be done even this year. As was truly stated here today – the teacher, the health worker and the soldier are the three pillars on which this country rests. This was truly an apt remark!

The fact that we have gathered here today to discuss the proposed programme for healthcare modernisation convinces me that this is a timely programme and the road we have chosen to this noble goal is the right road because I see talented and concerned people in this audience, and I am grateful to you. Thank you very much!

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Letters sent to Prime Minister Vladimir Putin following the Russian National Forum of Medical Workers

Mr Prime Minister,

We have always believed without reservation in the undertakings we carry out with your support, but, admittedly, the remarks of Leonid Roshal at the Forum of Medical Workers have undermined our faith in our calling.

His speech spurred pessimism towards our policy in those who attended the forum and left a bad taste in all of our mouths. You know better than anyone how highly committed we are to our cause. We do everything possible and even impossible to meet deadlines and develop truly comprehensive and intelligible documents. Leonid Roshal accused us of incompetence and poor managerial skills, despite the fact that this has been repeatedly disproved by our colleagues from the regions, who often turn to us and receive thorough consultation.

It is lamentable that Leonid Roshal criticised the healthcare policy of the government and our ministry without offering constructive alternatives. An analysis of our performance shows that there are major positive trends in the industry. Due to federal support and our prudent spending policy, we have managed to instil order in clinics and hospitals through administrative measures alone. For example, we have compiled isolated regulations for different medical services into unified guidelines, which will serve as a reference book for doctors, managers, and practitioners. We developed new standards in cooperation with the regions, thoroughly calculating and justifying each figure. This will pave the way for making quality medical care available to all social strata. New healthcare standards will be comparable to their international counterparts, and we will guarantee pay raises in the industry without putting an extra burden on regional budgets. This was done for the benefit of ordinary people and medical workers – not in our interests.

Of course, we understand that the state must not constrain freedom of speech and democracy, but, on the other hand, it is unacceptable to provoke conflict and breed alienation between us and our colleagues: doctors, nurses, and other medical personnel. After all, without their support, we will be unable to implement the modernisation programme. Moreover, our every step will be questioned. We have seen more than once new undertakings being met with scepticism and criticism, but our faith and confidence in the propriety of our actions always filled our colleagues with optimism and energy. However, we would not be surprised if this speech, which discredits our ministry, causes even more serious negative consequences.

Roshal’s hobnobbing and unrestrained behaviour at the forum caused sincere bewilderment and derision, even if at first his remarks were not taken seriously. It was not until later that our colleagues in the regions reacted with condemnation.

In our view, not all of Leonid Roshal's statements were at all well-conceived. We used to heed his opinion, but he has compromised his reputation in our eyes. Our opinion of him diminished still more upon checking his professional background, as we were forced to do. If he intended to damage the work we are doing, to question and subvert the cause to which we devote all our time, then he has achieved his goal. But we are confident that not all administrators, doctors, and nurses think like Leonid Roshal. And this has been proved by their response shortly after his speech at the forum.

Instead of allowing us to enlighten our colleagues on how to increase satisfaction in the quality of healthcare, increase life expectancy rates, reduce mortality rates, make medical services more easily available, and raise wages in the industry, Leonid Roshal sabotaged the work of the Ministry of Healthcare and Social Development and its branches in the regions.

The other day, the assembly halls were filled to capacity – people not only sat in additional seating but stood in the aisles for over four hours, demonstrating their concern and support for the healthcare and social development policy of the government and consequently for the ministry.

We would like to note that the ministry receives not only letters of complaint but also a great deal of letters in which people thank us for thinking strategically and making the best possible decisions, asking us to further develop healthcare and achieve even greater results. But this fact is usually sidestepped or ignored. It is hardly possible to deal with those problems that were mentioned – and even more so those that were not – over such a short and critical period of time. It is highly challenging, or even revolutionary, but over time, things will settle down as we learn to take greater advantage of past experience and of our current achievements.

Mr Prime Minister, please excuse us for taking up your time, but this has become quite a sore point for us. How much longer will he be blackwashing a federal executive body that employs ordinary people who use our healthcare services like everyone else? We would like to ask you to protect our honour and dignity against such criticism, which can hardly be called constructive.

The Ministry of Healthcare and Social Development

Mr Prime Minister,

I am an ordinary gastroenterologist. I work at an ordinary clinic – it's not fancy or corporate, just a municipal clinic in Moscow.

My colleagues and I watched the live broadcast of the Forum of Medical Workers. And there is something I have to say about it. How much longer will we tolerate idiots like Roshal, who rise to the stage only to hurl mud at those to whom they owe everything?

I’ve lived a long life and have worked in Moscow healthcare for years. And I can pretty well remember him as an ordinary physician – he’s never even worked as a paediatrician. And he received his certificate only because he’d been hounding Ruslan Khalfin. He really got on his nerves in the end. And he was awarded the professor title only because in the rampant mayhem of the '90s, you could receive a title or a degree simply for writing a monograph. That’s how he received his. Many received titles that way, and he was no exception.

I would never resort to writing such a letter to a prime minister, but I can’t keep it to myself. How dare he make you look for excuses? Who does he think he is? He’s neither a good organiser nor a manager.

He dared lash out at the Healthcare Ministry, but what has he done to improve healthcare as a member of the Public Chamber? Pushed through healthcare plans on behalf of those who wanted their own ideas on the books? He didn’t bother to read a single document, but he doesn’t hesitate to make his judgments known.

Mr Prime Minister, I would like to ask you to sort this matter out and restore the faith in your actions.

Sincerely,

Andrei Petrovich