Vladimir Vladimirovich (Putin), dear friends,

At long last the Ministry of Healthcare has engaged in a direct conversation with us, something we all have long been waiting for. Of course, this is not yet a congress of Russian doctors, but it is a dialogue, and there is nothing to be afraid of because our people are level-headed and they say the right things.

Both Vladimir Putin and Tatyana Golikova have told us all the good things about our achievements. Indeed, so many facilities are being opened, put into operation and built. Only a blind or embittered person does not see this. I can talk about the good which concerns me personally: over the past years the Institute of Child Traumatology, the only one of its kind not only in Moscow, but in the entire world, has been built. This experience can be spread and such children’s hospitals must be built across Russia.

My reason for speaking today, however, is not to praise what we have done, but to identify the sore spots. Regarding children, we need to step up real programmes for them. We should think about providing free medicine for children under 12, as is done elsewhere in the world. And Alexander Baranov (the Ministry of Healthcare’s Chief Pediatrician – L.R.) repeatedly raised the issue of building rehabilitation centres. This is particularly important because we will treat underweight children.

But first let us look back at history. When you were the President, Vladimir Vladimirovich, you sided with us and not with Zurabov who said that healthcare did not need to be financed. That was in my time. You can confirm that this is true, with the first evidence of such being the National Health project. Money was allocated, and the fact that some of it disappeared from under our noses is not your problem but one for those under you. But anyway the primary foundation, which was crumbling because of horrible pay, was salvaged. And the Finance Ministry and the Ministry of Healthcare have forgotten that polyclinics also have specialists, doctors for schools and preschools, ward heads whose salaries had not been raised, thus causing huge problems. We were all aware that the project could not solve all of our old problems and cure all the flaws in health service that had developed over the years. Equipment and machines, however, had been bought, and by 2007 we began to constantly remind the President’s Administration and the government of the need to increase healthcare’s share in the gross domestic product from a disgraceful 3.5% to 6%. We are not talking about 8–10–15%, like in other countries and we are not converting spending in dollars to roubles, rather we are speaking in terms of percentages and mentality.

Then, however, the economic crisis broke out. I can safely say that but for the crisis nobody would have been able to match our healthcare structure, which is the best in the world, if we had at least 6% of GDP and used it rationally. Working against heavy odds, we tried to preserve the social sphere. Of course, it sustained damage but still it did not revert to the level of the 1990s, which is a good thing.

An opportunity has been found to earmark an additional 460 billion to healthcare. That is a lot of money and we should see to it that it is not siphoned off and that it is spent in the right places. This money must not only be put under the supervision of the Prosecutor’s Office, but also of public medical organisations.

I can tell you a story of how public funds can be embezzled. We have an ongoing programme for reducing the rate of injuries in automobile accidents. I came across an item in the programme entitled “Designing a first-aid kit for drivers” and I saw a figure of several million roubles. I could not believe my eyes. How could this have happened? As a result they threw out medicines from the kit, as if we were living in Europe where medical aid is always around the corner, and added several bandages. Whether the designers were paid this money I do not know, but somebody had put that figure in there.

The additional funding will increase healthcare’s share in Russia’s GDP to 4.4%, as I have calculated, but not to 6–7%. On the whole, healthcare in this country gets about half of what it needs. Against that background – I may or may not be wrong – one can trace things back to the Finance Ministry’s and the Ministry for Economic Development’s stance of throwing a rope over our necks and limiting budget financing.

Vladimir Vladimirovich, if that happens, not only we will suffocate.

We have introduced the concept of profitability in our healthcare – that is a disaster. Hospitals and polyclinics are being shut down without making provisions for lending aid to the remaining ones.

One day I exited off a highway and stopped at a village. I saw a woman of about fifty and asked her, “How is healthcare holding up in your village?” I will give you the gist of what she said without the emotional language she used: the first aid and midwifery centre has been shut down, with the nearest one now 30 km away. We have one doctor. You can’t get through by phone to the ambulance. The bus fare has become very high and buses themselves don’t run very often.

Who needs this kind of reform? We think about money. The rouble now comes first and people, with so much emphasis on profitability, are being thrown to the wayside. And the same goes for the medical professionals. It is good that the situation is turning around. But perhaps it is too late now? Who is to answer for this?

We rush to relay to the head authorities that so many hospital beds have been cut and so many hospitals themselves have been shut down. In the Soviet Union this type of quickness earned you a passing Red Banner. And what is the reward now? It is easy to destroy a system, but it takes a lot of time and money to restore it.

As for the personnel issues. Think about the artificial administrative division in a district when there is the city healthcare department and the district one in the same place: the managing personnel, as a result, doubles. I think the system that we used to have was at least as effective.

Another new fad is to cut the number of beds in hospitals. Yes, hospital treatment is more expensive and it is cheaper in polyclinics. But in order to follow that trend we should do everything to enable polyclinics to serve all the patients, provide them with drugs and disposables, like in in-patient hospitals.

Personnel issues are now being discussed. As it turned out, there is a 30% shortage of medical personnel in rural areas. I may add that the same goes for the cities. Five years ago the Public Chamber Healthcare Commission sounded the alarm about this. But who even pays attention to it?

We are short of emergency room doctors, anesthesiologists, dermatologists, neurosurgeons, X-ray specialists manning heavy technology, autopsy specialists, and we are very short of specialists. There are regions where more than 50% of doctors have reached retirement age and only 7% of specialists are young people.

We, President Putin, would like to see a genuine national programme for putting an end to the personnel shortage.
A doctor’s salary at municipal hospitals is around 8,000 roubles a month. Unlike civil servants, who are able at least make ends meet on their salary, we cannot and must not do ten or twelve shifts in order to make 15,000 to 20,000 to survive. There is no time for improving one’s qualifications.

You have mentioned interns and postgraduates. I don’t know when their position will improve, but today I am ashamed to look my postgraduates in the eye: they earn a little over 2000 roubles. Who is responsible for this? This was written down by some people.

Another question: we have all been ordered to introduce a new pay-roll system. The argument was that it would be better: the pay would be higher and the service quality would improve, etc. I had a visit from Deputy Minister Oleg Safonov who talked to me for three hours about the new pay-roll system. And yet our old differentiated system with 18 qualification categories had incentives built into it. Why are you discarding it? Who thought this up? Is there anyone who can be held responsible?

Those who work in the system of mandatory medical insurance should have fees increased by two or three times to cover all of a medical institution’s costs.

Why is it that we only get money for a month (110,000 roubles) for treating a child in intensive care with serious multiple injuries? Let me deliver that child on a respirator with a head injury and for whose life one can still fight to the home of whoever wrote these new rules. He may be laid up for as long as 50 days. Not because we want him to, but because it is necessary. And it costs more than 400,000 roubles. Where shall we get the money to treat that child? From the doctor’s salaries?

As a result – perhaps we are in some kind of a transition period – based on the mandatory medical insurance accounts, we have been receiving not more, but less, in spite of the fact that the ratio seems to have been increased.

At the same time we squander money away. Just take, for example, computers. I come to a city and go to an outpatient clinic. I see a computer. I ask, “does it work?” In reply I get, “we have a contract with some programmers from Moscow. They are installing software.” I come to another city and it is the same thing: “It is not yet working. We found a company in Moscow, we have paid the money, and they are in the process of installing…”

What does one make of all this? We are working on an integrated programme for many years and we have still not finalised it and handed it over to all the outpatient clinics. In the meantime we incur huge extra costs. And providing computers would spell great benefits. In a children’s hospital in Orenburg I was given a password and I entered the system without leaving the office. I looked at the reception desk and I saw the size of the queue. “Can I look at the doctor’s office?” “No problem.” “Can I see how many patients this particular pediatrician received yesterday?” “Sure enough.” “Perhaps they have the diary, the description of the treatment and the prescriptions?” “Yes, and the network comprises the hospital and 8 outpatient clinics.” What is there to think about? Come and look what it costs and use it at your place.

About legislation. You know my position, I have presented it many times. But they don’t want to listen to civil society representatives. We are seen as gnats. Look at the draft law on health safety. The section on medical associations and citizens organisations has been curtailed. Do we not need them? Or will a separate law be written for them later? Tell the Medical Chamber to prepare that section. We have smart people and there are no enemies among us.

We have been demanding the strategy for developing the healthcare system for many years? Where are they leading us? Tell us please. Let us discuss the strategy at a medical congress. And then let us write the laws matching it.

Instead, they fudged the issue. They chose another approach. First they passed laws on the quiet side, without a strategy. And now the strategy will be tailored to these laws.

Regarding the mandatory medical insurance or new forms of ownership – autonomous, budget supported, state-owned and operated – first you should have a pilot project in one or two regions and only then pass the law. Mr President, why are the names of those who draft these laws hidden from us? Do you know why?
I will repeat because I see that they are keeping the president from listening.

Vladimir Putin: They must be doing it on purpose.

Yes, I am watching you, they are distracting you from one side and from the other side.
I am asking: why don’t we know the names of the authors of these laws? If there are many names, we don’t mind, we will read these names. The country must be able to recognises those responsible

Vladimir Putin: Nobody is hiding the names of the authors, they can easily be found.

Law 94 FZ has caused great harm. It is now being corrected, and that is right. But the Ministry of Economics sprang another surprise. We have received Executive Order No. 601. Have you received it? It is called On Approving the List of Goods and Services for the Customers Needs. The new system of procurement which combined groups that cannot be combined, for example, antibiotics and anti-flu drugs. Now every quarter we can buy either one or the other. Or take group No. 96: they lumped together cotton wool and X-ray equipment. That will simply bring us to a halt. Such laws and executive orders simply discredit the authorities. It is as if somebody were doing it on purpose.

There is one more fact which shows that civic organisations are not taken seriously. We have held, together with the trade unions, the first conference on self-regulation of professional activities. It was attended by 70 regions and the decision was sent to the Ministry of Healthcare and Social Development. We received an answer, signed by Vladimir Belov, six months later. It is an extraordinary specimen of bureaucratic prowess: it was about anything but the specific proposals that we had made. It is posted on the site of the National Medical Chamber, you can read it. (And I have a hunch, Vladimir Vladimirovich, that I received that answer because they got wind at the Ministry that I had visited you and handed over our decision to you). Belov is a fine specialist, a financier, a graduate of the Water Transport Institute in Leningrad. He may or may not have had a grasp of the details of the issues that were raised in our decision.

I am an outspoken man and I must say that it is a disaster that the Ministry of Healthcare and Social Development does not have a single normal experienced healthcare manager (applause).

I have questions from some people from the Ministry of Healthcare. I have a question for Olga Krivonos, she is holding her head down. She was once explaining to Tatyana Golikova that the ambulance service must come to the hospital and to continue working with the patient it has delivered. Those who may need an ambulance can say goodbye to it. When the ambulance brings a child with multiple injuries to my institute, it warns us, and the patient is met at the reception ward by an emergency room specialist, a neurosurgeon, an emergency injury specialist and a general surgeon. That brings specialised assistance close to the patient. Using an ambulance doctor at a hospital is not the answer…

Another problem is the difference in per capita rates in different regions of the country; the difference in fees which have not been revised for several years. We are one country. Why should a person suffer if he was born in a subsidised region which does not have enough money for healthcare? The distribution of healthcare authority between federal, regional and municipal levels is ill-thought out. We collect money from all the regions and then divide it up.

The National Medical Chamber has become the largest association of medical professionals second only to the trade union. It is an irritant. Today, we have about 200,000 medical professionals and about 50 major organisations.

We are creating the institution of independent expert review, arbitration courts and professional activities insurance. We are ready to work by signing an agreement between the Ministry of Healthcare and Roszdravnadzor [Federal Service on Surveillance in Healthcare and Social Development]. The aim of the Medical Chamber is to safeguard the patient against inferior standard of treatment and doctors’ mistakes and to safeguard the medical community against unfair criticism and unjustified material claims and law suits. We do real things, we are not word mongers. We are the only organisation that protects medical professionals if they are right, if they comply with ethical norms, if they do not violate treatment protocols and clinical recommendations. We engage exclusively in professional activities.

We are only beginning to work; we are about a year old. All of a sudden the Public Chamber of the Russian Federation started creating another medical association. Why? You don’t like the people or their work?

Yesterday I learned by chance that the Ministry of Healthcare and Social Development has decided to create a similar structure. I hope we can sort that matter out in a routine way. In Germany membership of the National Medical Chamber is mandatory, it is 130 years old. The Government there was not afraid to entrust to that citizens’ organisation the business of attestation, certification, the development of standards, protocols and monitoring of compliance with them. While here 30% of the population are satisfied with the doctors they have, in Germany the figure is 80%.

And one more thing: over there a medical professional studies all the time. The state and the patients are interested in doctors knowing more. Only a dramatic change of the post degree education system will make a difference. The doctor who goes away to study must be paid the regular salary, the state must underwrite the cost of training. It is necessary to calculate how much it would cost and start doing things, perhaps step by step.

Voices from the floor: stick to the time limit. You are taking more time than the Prime Minister.
Vladimir Putin: Leonid Mikhailovich and I are friends, he recently came to me and he was telling me all this, but today he wanted to share all this with everyone.

May I complete my speech?

Vladimir Putin: I am asking you to do it.

I like to say that a good doctor will cure a patient even in a barn and a bad doctor won’t even if he has a computer tomography.
The patient can be protected only in the framework of self-regulation of medical activities and self-organisation. Perhaps what the specialists of the National Medical Chamber propose can be done by the leading specialists and the Health Ministry? No, they can only do part of that work.

Vladimir Vladimirovich, no one comes to you and says, “I’ll give you the money.” In my own speech I have asked for money for one thing and another thing. When I am asked, “where will the money come from?” I reply: “From a wallet, if there is one”. I wish you health and a very large wallet.

Vladimir Putin: Just to make it clear for our colleagues, I have asked Leonid Mikhailovich to speak. Even though I knew in advance that his speech would be controversial, hard-hitting and professional, and in some ways naïve. But the naivety comes from the wish to improve things and that is the main goal.