24 april 2013

Meeting of the Government Commission on Healthcare

Transcript of the beginning of the meeting:

Dmitry Medvedev: Good morning everyone. Today we are holding the first meeting of the Healthcare Commission. It is a representative commission and I hope its work will be substantive and of course we will discuss various issues concerning demography in general and healthcare. Taking part in the commission are representatives of civil society and religious denominations, and the heads of various agencies whose policies influence the state of healthcare in one way or another. I hope this commission will  pass important decisions, related above all to life expectancy and people's quality of life and the building of a modern and competent system of affordable medical care. Of course people’s health depends not only on the quality of healthcare, but on their lifestyle, on how they look after themselves, on the environment, the conditions for effective work and decent proper rest.

At our first meeting today we will discuss a range of measures concerning preventive measures. What can be done? Although life expectancy in this country has reached almost 70 (a good result , because only recently when we were getting to grips with healthcare issues, life expectancy was very different, and we have covered a lot of ground within just five or six years), our country is still lagging behind the majority of developed countries, especially in the European Union and North America. The experience of some countries shows that it is possible to cut the death rate by half and even more within just 15-20 years. That of course calls for a proper diet, regular exercise, not smoking, not consuming too much alcohol and certain other factors.

In recent years we have passed the necessary decisions and the legal framework has changed. A law On the Basic Principles of Healthcare in the Russian Federation has been passed, which assigns priority to prevention and also the Healthcare Development state programme, which includes the subprogramme Prevention of Diseases and Promoting a Healthy Lifestyle. There is a range of priority tasks we have identified. These tasks stem from the presidential executive orders we have mentioned and from the Government’s  Policy Priorities. We have approved substantial financing for these purposes for 2013 as well as the planning period of 2014 and 2015 – over 76 billion roubles.

Now, about what we need to do. First of all, we need to give special attention to public health issues concerning children and young people. Nearly all state and government programmes in education, physical fitness and sport, culture and the environment, and of course in healthcare, include proactive measures. There are a lot of good programmes, but it is essential that these programmes be effective and work at all stages of education – in kindergarten, middle school and up. The necessary conditions need to be created.

As for pre-school education programmes, this is a complex and important issue. I met with my colleagues yesterday to discuss the current financing issues. Taking into account my previous instructions, we have decided to begin financing the programme to build more kindergartens in the regions. I will remind you that there are three main components here. Firstly, there are regional programmes funded by the regional governments (some regions are able to allocate more than others, of course); secondly, there are plans to set up private kindergartens for children; and thirdly, there are joint projects to build more pre-school childcare institutions. I have discussed this problem with several regional governors. Most of them, I must admit, believe that they require additional support from the Government. They cannot shoulder this alone, because unfortunately, the system of educational institutions for children under the age of seven degraded during the 1990s. Their number plummeted sharply, as their former premises were sold off to other businesses, and we have not been focusing on this issue since then. Now we are going to make it our priority. The joint projects I mentioned should become the driving force that will help us improve the situation. Overall, we need to set up or expand institutions to serve an additional 1.2 million children.

This programme essentially falls into the three large components I discussed earlier. The third one involves joint construction projects in which the federal Government will provide co-financing. Yesterday I decided to provide the first tranche of federal financing, in the amount of 50 billion roubles. This is a large sum. Over the next three years, we are planning to contribute hundreds of billions more, and I hope that this funding will help resolve this problem and also work as an incentive for the regional authorities.

This is actually part of the Government’s demographic policy and part of our public health system. I would like to call all the governors’ attention to the fact that the instruction I issued last year is starting to materialise. And, as with any instruction involving the allocation of huge sums, the process should be carefully supervised.

My second point concerns people under 60. In this age group, nine out of ten deaths are caused by non-infectious illnesses, not only in Russia but in the world as well. This is probably linked with the development of modern civilisation. The main causes of death include circulation disorders, respiratory diseases, cancer and diabetes. Therefore, people’s awareness of risk factors needs to be increased and they should be motivated to take care of their health before any serious treatment is required. Public health programmes should target a variety of population groups.

My third point concerns the recently adopted anti-tobacco act. To tell you the truth, it was not easy to push through this law on protecting people’s health from tobacco smoke exposure and the consequences of smoking. We’ve been through a lot of debate. But finally, this law was adopted. I hope that it will help reduce the risk factor and reduce the number of smokers, especially among young people.

According to experts (I have given this figure already), this alone could save up to 200,000 lives in Russia annually. That’s the population of a fairly large city or a region.

Fourth, much depends on the level of nutrition and quality of foods sold at grocery stores. We have harmonised sanitary and epidemiological requirements for food and goods, especially for children, within the framework of the Customs Union. This work will continue.

Fifth, sport. Of course, sport activities should be accessible to people from all walks of life, regardless of their age, physical abilities, and, what is particularly difficult, their geographical location. We are faced with serious problems in this area, although the number of different kinds of sport facilities has grown significantly in recent years, including in regions that are located far from Moscow. However, this work must continue. This is not just the work of the state, it is also part of the responsibility of civic organisations, businesses and political parties. I believe we should join our efforts. To do so, we will need new approaches to urban planning providing for building parks, bike paths and walking trails in residential communities.

Finally, interdepartmental cooperation is of paramount importance, as is the coordination of efforts by and between authorities of various levels. Regional comprehensive prevention programmes are now being implemented in 60 regions, and 23 regions are developing such programmes. But there are problems, because these programmes are often fragmented, due in part to funding problems. In any case, we need to put together a plan of action, a road map that will synchronise the efforts of various departments and authorities and consolidate our efforts in the most important areas.

Once again, I would like to say that it is very important to coordinate the efforts of the state, government, civic organisations, traditional religions and the business community in this work. It is also important to spread the success of the regions. Our meeting today is being attended by governors of the Ryazan and Vologda regions. There are positive examples in other areas and I hope that our colleagues will share their successes with us today and show us how we can replicate their experience in other regions.

Let’s begin the discussion. I will turn the floor over to Minister of Healthcare Veronika Skvortsova. Go ahead, please.

Veronika Skvortsova (Minister of Healthcare): Thank you. Mr Medvedev, members of the government commission, promoting the human potential is the most important goal and a prerequisite for the social and economic development of any country. Epidemiological studies conducted in 100 countries between 1960 and 2000 have shown that an increase in life expectancy by one year increases the gross domestic product by 4%. Thus, the planned increase of life expectancy to 74.3 years could increase the GDP by 20%.

According to the WHO, 10% of health and the life expectancy is determined by the state of healthcare and the quality of medical care, 10% is related to genetic factors, and 20% to environmental and climatic factors. Lifestyle accounts for up to 60% of a person’s health.

In the structure of mortality, factors associated with destructive behavior account for up to 30%; 11.9% of deaths are related to alcohol consumption, 17.1% to tobacco smoking; 25% to excessive and unbalanced diet, and 9% to sedentary lifestyles.

As Mr Medvedev has already pointed out, 9 out of 10 deaths of persons under the age of 60 are due to noncommunicable diseases associated with the above-mentioned risk factors. The issue is about the global epidemic of noncommunicable diseases. Thus, the reduction in the incidence of noncommunicable diseases and related mortality is a major concern in all economies, both developed and developing.

Dmitry Medvedev: In terms of classification, can there be an epidemic of heart diseases? For us, who are not doctors, it sounds rather strange. Is that the way that we classify them?

Veronika Skvortsova: We can classify them this way, Mr Medvedev. In fact, it is a global epidemic. One of the Millennium Development Goals set by the United Nations ...

Dmitry Medvedev: So, for the purposes of development it’s classified as an epidemic, correct?

Veronika Skvortsova: Yes.

Dmitry Medvedev: Interesting.

Veronika Skvortsova: The positive experience of a number of countries, including neighbouring Finland and Japan, shows that the mortality rate can be halved in a matter of 10-20 years mostly due to preventive measures that are many times more effective than treatment.

In 2010, the concept of a unified health-saving preventative environment was developed in Russia, and was presented at the World Health Assembly and adopted by the international community. Moscow has been chosen to host the first Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control. It took place in April 2011. The Moscow Declaration laid the foundation for unified international approaches in this area. It was approved by a special WHO resolution and was included in the political declaration of the General Assembly on the Prevention and Control of Noncommunicable Diseases held in New York in September 2011.

In November 2011, a system-wide industry-specific federal law, On the Basics of Healthcare in Russia, came into force in Russia, which focuses on prevention. The package of preventive measures was included in the Government programme, Promoting Healthcare, which was adopted in December 2012. The priority areas include providing a safe and comfortable physical and social environment, encouraging people to preserve health and be responsible for their own health, and forming an effective health management system for each person.

Resolving these problems is beyond the competence of a single ministry and requires joint action by the majority of federal and regional authorities that operate in healthcare sectors, as well as civic organisations, religions and civil society as a whole. Thus, providing a safe and comfortable physical and social environment, including the workplace, is the shared responsibility of the Federal Service for Supervision of Consumer Protection and Welfare, the Ministry of Labour, Ministry of Economic Development, Ministry of Industry and Trade, Ministry of Natural Resources and Environment, Ministry of Regional Development and the Federal Service for Drug Control, as well as all other departments that are involved in providing a safe social environment. The competence of the Ministry of Agriculture, the Ministry of Industry and Trade, the Federal Service for Supervision of Consumer Protection and Welfare, the Ministry of Education and the Ministry of Healthcare includes providing people with safe and nutritious food and forming a commitment to a healthy lifestyle and eating habits.

Domestic and foreign experience shows that the most stable behavioral patterns take shape at an early age. Moreover, the upbringing and education of children by their parents and other adults exert an indirect but strong influence on the formation of a healthy lifestyle. The Ministry of Education and Science, the Ministry of Sport, the Ministry of Culture, the Ministry of Communications and Mass Media and the Ministry of Healthcare are responsible for motivating people to be healthy through their involvement in large-scale physical fitness and sport and moral education. They must implement psychologically adjusted educational programmes for all ages and social strata by using multimedia resources: the media, modern information technology and interactive communication with the public.

Effective performance of all departments must be provided with adequate funding and legislative regulation. Prices and taxes, including excise duties on harmful tobacco and alcohol products, should encourage people to lead a healthy life style and make employers more responsible for public health.

The federal law on the protection of health against tobacco smoke and the effects of smoking adopted in 2012 contains a number of measures aimed at encouraging people to quit smoking. However, we must continue the work on prices and taxes, because international studies show that they are the most effective in combating smoking. This work is the joint responsibility of the Ministry of Finance, the Federal Service on Regulating the Alcohol Market, the Ministry of Economic Development and the Ministry of Healthcare.

In addition to general preventive measures based on population strategies, we must introduce a mechanism for monitoring the health of every Russian citizen. In this context, the Ministry of Healthcare is developing high-risk strategies aimed at individual preventive care.

We have launched standard medical examinations in January 2013. The goal is to determine the main health parametres of every person; to reveal and remove risk factors that influence the quality of life and life expectancy, and draft recommendations on lifestyle changes or other health-related measures.

Most of the current state programmes and government concepts provide for health-building measures. Considering the best world practices, it seems rational to charge the Ministry of Healthcare with the coordination of all health-building measures under the auspices of the Government Commission on the Protection of Public Health. The Ministry should coordinate all health-building spheres, relevant departments and civil communities. It should also build a system of priorities and determine inter-departmental relations in this sphere.

This organisation of work will fully meet the tasks set forth in the Presidential Executive Order of May 7, 2012 that instructs the Government to continue implementing measures to promote a healthy lifestyle. Carrying out this order and the state programme on developing healthcare to 2020, we must achieve serious targets, one of which is to increase the life expectancy to 74 years.

A number of pilot drafts of comprehensive preventive care programmes carried out by the Ministry of Healthcare in the Ryazan and Vologda regions have already proved that we can reach these targets. In 2006, several Russian cities – Cherepovets, Stavropol, Cheboksary and Novosibirsk – formed an association of healthy cities analogous to the WHO European project with a view to implementing modern social strategies and elaborating new approaches to public health. In 2010, it was turned into the Association of Healthy Cities, Districts and Villages.

Today it includes 21 cities and six federal districts. Such initiatives of non-government expert, public and religious organisations are an effective mechanism for implementing state demographic and healthcare policy. Moral health determines the condition of everyone’s psyche and physical health.

To sum up, the commission organised under your leadership makes it possible to coordinate the activities of all federal and regional executive bodies and our entire civil society on preserving and improving public health and extending active longevity. We’d like to ask you to instruct all interested federal and regional executive bodies to provide us with information on their performance in promoting public health and plans for upgrading it. Please, instruct the Ministry of Healthcare to sum up this information, draft a roadmap of inter-departmental health-building measures and submit it to the Government. Thank you very much.

Dmitry Medvedev: Okay. I’ll sign an instruction on the roadmap, of course. But let me repeat it is much more important to implement this roadmap than to use it as a guide for different actions that have been approved at top level.

Let’s hear from the regions. I’d like you to make brief accounts. Let’s start with the Vologda Region. Mr Kuvshinnikov, please go ahead.

Oleg Kuvshinnikov (Vologda Region Governor): Mr Medvedev, ladies and gentlemen. I’d like to describe the experience of the association of healthy cities that started working in Russia in 2006. I’ve chaired it since 2010. We are aware of the challenges that Russia is confronting in the early 21st century – aging of the population, the reduction in the economically active population and a negative demographic trend. Naturally, we must create a favourable social environment for the development of the human potential in order to reach the targets of socio-economic development. We need a healthy, socially stable and economically active competitive society. I fully share the opinion of Ms Skvortsova – to achieve this we must adopt new principles and methods for state regulation of public health. First of all we should speak about an interagency and inter-sectoral approach to public health management, the involvement of all agencies and all levels of government in implementing this project. Of course, we need to develop criteria for assessing the effects of the decisions we make. As you have rightly said, Mr Medvedev, we need to harness non-governmental organisations, public-private partnerships and public institutions, such as Russia’s Healthy Cities Association, the Health of the Nation League and others. If we are to see harmonious human development we have to create conditions at the municipal level, get the residents of municipalities involved in implementing this strategic project.

Next slide, please. We took as our starting point the global and European experience, the World Health Organisations’s Healthy Cities project which is made up of 1,500 cities in 55 countries; we have studied the practical experience and since 2006 have been implementing this project in Russian cities. It already involves 21 cities and more than 10 million people and of course we have some concrete results to report.

Next slide.

Dmitry Medvedev: I just want to understand what exactly “involvement in the project” means? Are the people involved in the project actually doing something?

Oleg Kuvshinnikov: In three slides time I'll give more details…

Dmitry Medvedev: I see, you need three more slides to get there. Okay.

Oleg Kuvshinnikov:  And of course I would like to comment on how we've tried to make these people aware that they need to do something about their health.

The project was financed from the municipal budgets. The aim is to improve public health and create local conditions for this. Every city is different, so many cities are implementing projects aimed at improving the environment, occupational health, diet and so on.

The next slide shows that we have some early results: the cities covered by the association have a growing proportion of citizens who regularly engage in physical activity and sports, a growing number of people put health at the top of their list of priorities. The proportion of workers exposed to unhygienic labour conditions is going down and the demographic situation in the association cities is improving: natural population growth has resumed, life expectancy has reached 70 years, we have positive demographics and this is partly due to the involvement of the population in health-preserving technologies. The next slide will explain what that means.

To create a health-preserving space we have used instruments developed by leading world experts and by our association. First of all, this means training and education for the people who make health management decisions. Then of course the development of healthy principles in the spatial planning of our cities, including rapidly expanding districts, involving the public and civil society organisations in shaping health policy at the local level, the creation of a barrier-free environment, improved housing conditions, relocating residents from decrepit housing unfit for habitation, the overhaul of the housing stock – all this creates a common health-preserving space in our cities.

I would also like to cite an interesting example – you have been speaking about the intersectoral approach to tackling social problems, bringing in big business and private-public partnerships. Jointly with the region’s biggest metallurgical company, Severstal, we are implementing a project called The Way Home, aimed at strengthening motherhood and childhood, reducing the number of children left without parental care and improving public health. A quick rundown of the results of this project: over four years the number of children in orphanages has been cut by half, the number of children’s homes was cut by half from nine to five in Cherepovets, where they have been converted into pre-school childcare facilities, there is no waiting list in Cherepovets for children who have reached the age of three… All the children aged three to seven have places at pre-school childcare institutions. I would like you to take note of the fact that the number of socially vulnerable families and children, which is a highly relevant issue for an industrial city like Cherepovets, has gone down by 46%. Every year Severstal invests more than 60 million roubles in this project jointly with the municipal budget.

And something about structure (next slide). The association has an organisational structure at the municipal level and it has proved effective, as I said. An interagency coordinating council has been set up in every municipal entity, there are project offices called “Healthy Cities, Districts and Villages” and a project coordinator has been appointed.

The next stage I propose is to form an organisational structure in all the Russian regions. There must be an interagency project coordination council in every region. That would help to pool the efforts of all the state and municipal bodies in the public health area.

The last slide shows our proposals. First, to develop and start gradual implementation of the common health-preservation space strategy in the regions and municipalities in the Russian Federation. To test the new approach on a pilot project of the Healthy Cities, Districts and Villages Association. I am prepared to offer my Vologda Region as the location for the pilot project, we are ready for this. And I urge you to approve the model structure of managing health in the constituent entities of the Russian Federation developed by our association. Thank you.   

Dmitry Medvedev: Thank you. You mentioned Cherepovets. Indeed, you devoted a considerable amount of time to organising the work at that enterprise. What I am trying to get at is what incentives can be used to motivate people to lead a decent healthy life, because that is no easy task. It is easy to talk about it and give presentations, but people’s habits vary. There is, however, a set of habits characteristic of our population, of our people and it is hardly the best set of habits. Did you do anything in this area when you worked in Cherepovets and now in your capacity as Governor?

Oleg Kuvshinnikov: You know, Mr Medvedev, promoting a healthy lifestyle must be a strategic priority for every municipal entity. This is about our future, our children, the economically active population. We do this above all by shaping public opinion. Through occupational guidance, creating good conditions in the workplace, complying with the laws of the Russian Federation on limiting alcohol consumption, smoking, in short, it is a range of measures and it is a multi-functional approach. All spheres of the regional and municipal economy must be interested in this. It has to do with the building of roads, the construction of houses, environmental protection, the creation of leisure zones and the planting of greenery. So, it is a comprehensive project. The Healthcare Department cannot cope with this task on its own, we must bring all the structures into this project, including the media, which should promote a healthy lifestyle. We have made great progress in this direction but it is still not enough.

Dmitry Medvedev: All right, carry on. Oleg Kovalyov, Ryazan Region.

Oleg Kovalyov (Governor of the Ryazan Region): Mr Medvedev, esteemed participants in the meeting. I have been Governor of the Ryazan Region since 2008, and when I took office the situation in the healthcare system was appalling, simply lamentable. That of course had an impact on demographic indicators in the Ryazan Region: they were among some of the worst in Russia. So, the development of healthcare was chosen as a priority and over five years we invested heavily, with the support of course of the federal budget, of the federal centre. During the past four years spending on healthcare has virtually doubled, which has had a positive impact on demographics.

The birthrate, although there is a steady upward trend while the death rate is going down, is still among the lowest in the Central Federal District and the death rate among the highest in the Central Federal District and in the country overall. Therefore we are doing a lot to strengthen healthcare, to promote a healthy lifestyle, raise living standards and increase people’s incomes (all that improves demographics), step up the construction of low-cost housing, eliminate waiting lists for pre-school childcare institutions, create jobs and support vulnerable sectors of society.

The Ryazan Region allocates about half of the regional budget to address social problems connected with demographic policy, but even that is too little if we want to bring about a dramatic improvement. Please show slide 3. Surveys have shown that the risks of chronic non-infectious diseases in the Ryazan Region is higher than the average in the country. It was therefore decided to develop a regional long-term targeted programme to promote a healthy lifestyle and prevent non-infectious diseases in 2013-2017.  Fourth slide please.

Dmitry Medvedev: I see some interesting data here. I don’t know to what extent they reflect the real situation...

Oleg Kovalyov: What data?

Dmitry Medvedev: The health risk factors (Slide 3) in the Ryazan Region: low fruit and vegetable consumption. The lowest level is in the rural areas.

Oleg Kovalyov: This is what our statistics show.

Dmitry Medvedev: Anyway, I just want to draw your attention to that. I don’t know if it is the same in other regions, but it is curious. Go on, please.

Oleg Kovalyov: There is another table there which shows that alcohol consumption in the Ryazan Region is lower than in Russia overall and the Central Federal District, which also makes me wonder.

Dmitry Medvedev: It makes you wonder but you are still telling us about it.

Oleg Kovalyov: These are statistical data.

Dmitry Medvedev: Yes, indeed, I see that the alcohol consumption risk factor is lower in the rural communities. Look, the last column says 35%.

Oleg Kovalyov: Yes, I know, I see it.

Dmitry Medvedev: This also raises some questions because this is not the situation in many other regions. Unfortunately, rural folk usually drink more. You should pay attention to this statistic. Go on, please.             

Oleg Kovalev: Please, show slide four. The content, goals, tasks and targets of the programme are in line with the subprogramme Preventing Diseases and Promoting Healthy Lifestyle of the state programme for developing healthcare. The regional programme envisages raising awareness and targeted motivation for the population to lead a healthy lifestyle, taking into account age, sex, education through the media, through volunteers, through medical workers and social workers; creating the conditions to help people lead a healthy lifestyle and do more physical activity (over the past years we have built and opened, with the support of the Ministry of Sport, 12 sport facilities in medium-sized municipal entities such as small district centres with populations of 10,000 or 6,000); prevention of harmful habits; putting in place a system of early detection and correction of risk factors for the main chronic non-infectious diseases; promoting rational diets for children and adolescents. Taking part in that work are not only medical professionals but other specialists who actively work with civic and religious organisations. Funding for the programme totals 145.3 million roubles. Within two or three years this programme should reduce the prevalence of behavioural risk factors for chronic non-infectious diseases. In approximately five years we think that the rate of premature deaths from chronic non-infectious diseases will drop by at least 20%.

Slide six, please. At the same time, implementation of the measures to create conditions for healthy living requires adjustments to the existing legal framework, including, we believe, at the federal level. The following are outstanding issues that need to be addressed: creating mechanisms to encourage the population to lead a healthy life; a massive and ongoing public awareness campaign in federal and regional media to promote a healthy lifestyle with due account of the characteristics of various population groups; reviewing requirements for school and university meals in accordance with the principles of the healthy lifestyle and adjusting preschool and school programmes to introduce technologies that promote health. That includes educational facilities as well as the programmes themselves, and increasing the physical fitness component of the curricula and so on.

Mr Medvedev, we have adopted this programme in our region. We will implement it systematically and fully because the situation is critical: demographic indicators show that we must step up efforts in this area. Of course, we can only set aside an insignificant part of our budget for these purposes, and the effect would be much greater if we had federal support, which we are counting on. I hope that some approaches will be developed for co-financing, because there are some things that even a regional budget is unable to finance alone.

On the whole, the network of healthcare institutions is in place. There are only three healthcare facilities that we still have to build. We will build two of them under the healthcare modernsation programme – a medical centre for children and a new regional children’s clinical hospital. We also have to build a first aid hospital. I would like to ask for your support, because the Ministry of Healthcare has approved it but the Ministry of Economic Development rejected the project, even though we showed them the demographic statistics and the situation in our region. And one more thing: we are currently introducing major changes to how the healthcare system is organised: we are working on job descriptions and medical standards for doctors of various levels and medical institutions of various levels, we are establishing a system of interaction between different levels of healthcare. There are three levels: regional, inter-municipal and municipal. There is an inter-municipal level because some municipalities are very small and cannot offer the full range of medical services.

Thank you. That concludes my report.

Dmitry Medvedev: Yes, I am trying to understand. Of course, there has always been and will be support from the federal budget. But I want you all to understand that federal money that goes into the healthcare system is in fact support for preventative programme. But some of the things you have mentioned and that will in any case have to be fostered locally depend greatly on the resources of our families. Your presentation touched on modifying requirements for school and university meals to promote a healthy lifestyle. How will you go about this in schools?

Oleg Kovalev: To begin with, we are already doing this. For example, we upgraded the cafeterias in 60% of city schools and brought them up to modern standards. We will continue this work, Mr Medvedev. Support from the federal government is of course a factor here, because the money we spend on this is money made available under the education modernisation programme. Of course, if that programme continues to provide all the schools with similar cafeterias, that would be great. But even if no such decision is taken at the federal level, we will go on doing it because we think it is important.

Dmitry Medvedev: As for schools, this is something all the regions must see through. In my opening remarks I spoke about support for building kindergartens. Let me be frank, there are some in the Government who believe that this is not the business of the federal government but rather the regions. But considering what the situation was like 15-20 years ago I believe that the federal government must step in and allocate considerable resources in spite of everything, and we will make these contributions.

As for school meals (I want all the regions to pay attention to this), the programme to modernise the school food system must be completed. We began it as a pilot project in 2007, if you remember. I see you nodding…

Oleg Kovalev: I did not work there at the time.

Dmitry Medvedev: I am not blaming you for what has not been completed. But we have been at it for a fairly long time. Initially it was part of the so-called national project, and there were several regions that were doing it. We need all schools to complete this work.

Oleg Kovalev: As for preschool childcare institutions, we are building 12 of them, and of course, federal support will help us open them before the year is out, because it is difficult for us to accomplish it on our own.

Dmitry Medvedev: It is difficult to organise it quickly.

Oleg Kovalev: For three-year-olds we cover more than 80% of the need, and another problem is that there are not enough kindergartens in residential areas: mothers have to take their children on public transport to faraway places, and that complicates matters.

Dmitry Medvedev: Yes, that is also a problem. And by the way, our parents often choose more prestigious kindergartens and schools with better programmes even though they have to take their children there. It is the same all over the world. Children often have to travel long distances to school: it’s their parents’ choice. But of course, it is desirable that these institutions be nearby.