Meeting with healthcare sector workers 2018-03-16 16:45:00 St Petersburg During his working trip to St Petersburg, Vladimir Putin visited the Almazov National Medical Research Centre. At the centre, the President met with representatives of the Russian healthcare sector, patient organisations, medical educational institutions and medical associations. The meeting participants discussed a wide range of matters regarding the Russian healthcare system. Before the meeting, the President toured the medical research centre. Director General Yevgeny Shlyakhto demonstrated to Vladimir Putin a hybrid operating theatre that is unique in Russia. It is equipped for CT scanning to be carried out during surgery. One of the advantages of hybrid surgery is the ability to perform simultaneous interventions by several teams in the same operating theatre, which reduces the duration of an operation. This method also reduces the risks of any complications and cuts the time a patient spends at a hospital. The Almazov National Medical Research Centre is one of Russia’s largest research and medical facilities as well as a multidisciplinary research and clinical centre. The centre provides multidisciplinary specialised medical help to the public, including hi-tech procedures. Additionally, the centre conducts fundamental and applied research in various fields of medicine and trains researchers and medical workers. Every year, the centre treats over 36,000 patients. Over 170,000 people are received by the centre’s outpatient clinic. * * * Excerpts from transcript of the meeting with healthcare workers President of Russia Vladimir Putin: Friends, good afternoon, I hope that you too were shown around the centre where we are today. Despite the fact that I was directly involved in its establishment and development, it still impresses me a lot. This is exactly what medicine today needs: a blend of science, education, a clinic as well as personnel training. Magnificent! It is all these things put together that produce this upscale effect. The goal of our meeting, or this medical roundtable discussion, as I put it, is the following. If you noticed, in my Address to the Federal Assembly I spoke about priority development areas for Russia and singled out several of them such as infrastructure development: transport, communications, education, science, high technology and medicine. It is obvious that it is impossible to solve the main humanitarian task and the state’s mission without healthy people; it is impossible to help people to live longer and have a high-quality of life; and it is impossible to solve the key task every country has, ours included: the preservation and development of the nation. In today’s world, healthcare is becoming, or, to tell you the truth, has already become an economic category. And I do not mean the cost of sick leaves alone here. I mean that the main motivation in today’s world include advancement in science, technology, robotics and artificial intelligence. An ill person cannot solve these tasks, just cannot. In this sense, healthcare has a special mission; it becomes complex. You might have noticed that I have recently met with representatives from the transport complex in Moscow, talked with agriculture representatives and the agroindustrial complex in Krasnodar and met with representatives from the academic community in Novosibirsk. Before preparing the new edition of the 2012 executive orders, which you remember, we will need to prepare new goals based on the things we have done and the matters we are facing today. So, while meeting people from various professional fields, I wanted to meet people working in healthcare, too, with people doing practical work. I have just issued instructions to the Government and the Executive Office, and the work on specific executive orders on the areas of activity, on sectors, including healthcare, medicine, will get underway. I would like to hold a free, open conversation with you today. I would like to listen to your thoughts, your opinions and your recommendations on what we should do in the near future and how, in your opinion. If we talk about the year 2012 and these executive orders, then one of the most important components was wage levels in the healthcare sector. As you remember, the point was that doctors should receive exactly twice as much as the average in a corresponding region. I know about part-time employment problems, I know that not everything has been done, but still, progress has been made, it is noticeable, obvious. What would I like to say in this regard? If this bar were not so rigidly fixed, then we would not have achieved today’s result, because when there is no clear guidance and clear instructions about what we need to achieve, we go along general terms. As a rule, such things do not get special attention. In this connection, I would like to say and emphasise that with an increase in wages in regional economies, the Government will strive to ensure that the achieved level does not decrease but gradually rises. This is for starters. Before we begin the conversation, I would like to say the following. As you know, a new state decoration has been established in Russia – the badge of merit For Mentorship. And I am very pleased to note that such a badge is being awarded to your colleague, Rector of Samara State Medical University, Academician Gennady Kotelnikov. He is an outstanding doctor, a true teacher and a mentor who has trained more than 80 scientists in the field of medicine, 25 Doctors of Science and brought up a long line of wonderful doctors. I would like to congratulate you from the bottom of my heart. Speaker: In accordance with the Presidential Executive a badge of merit For Mentorship is presented to Gennady Kotelnikov, rector of Samara State Medical University, for his services in teaching young professionals and active mentor activities. (Applause.) Vladimir Putin: Mr Kotelinkov, I would like to congratulate you once again, thank you for your many years of work and I wish you every success. Let’s begin, please, go ahead. Yelena Kleshchenko: Good afternoon to everyone once again. I represent the Krasnodar Territory. Yelena Kleshchenko, head doctor at the Children’s Regional Clinical Hospital. First of all, Mr President, I must say that we were very encouraged about the declared Decade of Childhood. When we discussed it with colleagues, we thought it was a very good sign for our sector. I would also like to thank you for launching the unique perinatal centre construction project which is almost completed in Russia. We were in the first phase: our perinatal centre is seven years old. I believe we make a huge contribution into lowering the infant mortality rate: it was 4.3 in the Krasnodar Territory last year, and we are very proud of this. It seems to us that implementing more high technology into our field would be a breakthrough in helping children and reducing infant mortality and cases of disability. But this would require new medical buildings. I know that 17 Russian regions have no local children’s hospital at all, and children are treated at clinics for adults; this is why I am asking you, Mr President, with hope. Are there plans to build any children’s hospitals like perinatal centres? And, if you allow, another question. It is a very acute and serious topic for us: there is not enough medicine especially for children. As you know, when a pediatrician prescribes medicine, he or she writes the dose: milligrammes or millilitres per kilo of the body mass, and this body mass can be 500–600 grammes or 30–40 kilogrammes. This is why the lack of medicine for children is a grave and worrying matter for pediatricians. And I would like this problem to be discussed at the highest level. Vladimir Putin: Ms Kleshchenko, first of all, I would like you to note that the healthcare in the Krasnodar Territory is good in general. There probably are some problems, but in any case, your regional hospital can serve as a good example of how the healthcare sector must develop in the regions. You have everything there. Very good experienced specialists and good equipment. To tell you the truth, when I found out more about this, I was glad that we have got such centres in the regions. Speaking about the perinatal centre, you know that it was difficult to establish it although it has been working for seven years. At the beginning there were several mistakes, to put it mildly, that had to be corrected along the way, but we have managed it. To be quite frank with you, this is a good example demonstrating that every right and good deed has a few stumbling blocks to overcome. And we must never give up; we must move forward and achieve results. And when we set these goals, we always manage to do it. The example of your perinatal centre is very good, it proves these words. Speaking about children’s hospitals, clinics and so forth. You must have heard, I spoke about it maybe two months ago that we will allocate additional money to re-equip children’s clinics and departments at hospitals during 2018, 2019 and 2020 especially for this. This means an additional 10 billion from the federal budget during these years. On March 1, if I am not mistaken, or not very long ago anyway, the government issued the corresponding instruction. (To Healthcare Minister Veronika Skvortsova.) Ms Skvortsova, did you get that instruction out yet? It envisages 10 billion for 2018. I said and I would like to say it once again, that these funds are allocated for re-equipping children’s hospitals and departments at hospitals. You have spoken about construction. The government instruction and my instruction did not include construction. The only thing I am concerned with, and please do not get me wrong, I do not want to offend anyone, I am just afraid that this money will be used on endless construction, and not to re-equip, train specialists or fix what there already is. Unfortunately, it is very difficult to check up on such things as shrinkage, spillage and resorting. Although, we must probably think how to organise it in some cases where there is nothing yet. Maybe, we may reconstruct something, or maybe, combine hospitals already available. I do not object in general, but you must be very careful with this construction. Speaking about childhood and children, I said that additional 10 billion will be allocated. The decision for this year has been made. Now, on to subject of medicines for children. There is a federal programme called Pharma. It is strange that it does not contain a section on children’s medicines. It must be added. Do you have this section? Healthcare Minister Veronika Skvortsova: There is a section on medicines for children. There are 640 registered medicines for children, including 79 developed exclusively for children. Five or six new medicines are registered every year. There are anti-viral, anti-bacterial and other types of medicines being registered. We are monitoring the registration and will extend the list every year, by all means. Vladimir Putin: I think it is necessary that doctors are promptly informed. It often happens that something new has been developed but nobody knows about it. Veronika Skvortsova: Of course, it will be done. Vladimir Putin: So, we have this area covered. It just needs to be improved. We will do as required. Please. Valentina Zherebtsova: Mr President, I would like to support my colleague. My name is Valentina Zherebtsova. I work at the Children’s Neuropsychiatry Centre in Tula. I would like to support the request for not only constructing new and equipping existing children’s hospitals but also doing the same for children’s rehabilitation centres. Even more so because in the past years, a lot has been done in this area. There are clinical protocols for monitoring patients and professional standards in place. Modern technology is widely used in children’s rehabilitation. There are early treatment and diagnosis programmes. Therefore, we are witnessing some very significant changes. Of course, providing children’s rehabilitation facilities with newer equipment and constructing new facilities is a very important matter, in my opinion. However, my question is not about that. There are entire groups of specialists who are categorised as paramedics, such as speech therapists and neuropsychologists. They are full-fledged participants of the rehabilitation programme and the rehabilitation process. Up until now, these specialists have been trained at teacher-training universities or dedicated university departments. I believe it is important to train such specialists at medical universities for subsequent employment with the medical rehabilitation system … Vladimir Putin: I agree with you. Speech therapists are trained at teacher-training universities, and they major in what I believe is called ”speech therapy teacher.“ Valentina Zherebtsova: Yes, speech pathologist. Vladimir Putin: Yes. They work with otherwise healthy children to correct speech disorders. However, as far as I understand, what you just said includes work with children who have certain disorders, primarily, mental ones, or something else. Valentina Zherebtsova: Yes, it is about communication technologies for children who may never be able to speak. Vladimir Putin: Yes, but speech therapists are already being retrained at medical universities. I think certain changes can be made so that medical universities can start training them. The Ministry of Healthcare should work it through and that’s all. Veronika Skvortsova: Thank you very much, Mr President. We have been thinking about this, and we want to start training such specialists on September 1. Vladimir Putin: I believe now speech therapists are undergoing additional training at medical universities. Veronika Skvortsova: It is about providing basic medical training for neuropsychologists and aphasia specialists (speech-language pathologists who deal with secondary speech disorders caused by focal brain lesions). Vladimir Putin: I understand. However, I believe that speech therapists are now being re-trained at medical universities in order for them to be able to work with patients. Veronika Skvortsova: Yes, there are such trends. But my colleagues believe that … Vladimir Putin: They still need basic medical training? Veronika Skvortsova: Yes, basic medical training in addition to their regular training. We are ready. Vladimir Putin: Good. Please go ahead. Lyubov Agafonova: My name is Lyubov Agafonova, I am the Head Doctor at the Regional Clinical Hospital in Lipetsk. Mr President, first and foremost, allow me to thank you on behalf of the medical workers of our region and its residents for your support in implementing healthcare programmes. And a special thank you for the vascular health programme, which the region needed the most. The healthcare services we currently provide under this programme, including prevention of heart attacks and strokes, were never provided in our region before. We can now prevent heart attacks and treat strokes, thus reducing the disability status scale and saving millions of lives across Russia. And for that, a big thank you to you. Vladimir Putin: This is something that we have achieved through your efforts, and it is people like you who make it possible. Maybe not all the objectives have been achieved so far, but overall there is some clear progress on vascular diseases. It is telling that the mortality rate of these diseases is declining. It is true that we have taken a major step forward, primarily thanks to people who work in the sector. Of course, the state did its best to provide the resources. We must thank you for making use of these opportunities in such a smart and professional manner. We will continue our efforts. There are still challenges we have to overcome, and we will keep moving forward. Please, go ahead. Arcady Stolpner: Mr President, In your Address to the Federal Assembly you mentioned cancer treatment. And you said that there was a need… Vladimir Putin: Sorry to interrupt you. This is an area where unfortunately we have yet to achieve the results people expect from us. This is true. While we have made major progress on vascular diseases, and we have achieved a breakthrough, there is also some progress in cancer treatment, but not the kind of progress we would like to see. Sorry for interrupting. Please, continue. Arcady Stolpner: In fact, I wanted to talk about the positive developments. When this disease strikes any of us, our friends or relatives, it is a tragedy. It gets even worse when dealing with cancer in children. But new methods for treating oncological diseases have been developed recently. Proton beam therapy is one example, often mentioned by Ms Skvortsova. Children are the focus groups for this therapy, and it is often the method of choice when treating cancer in children. We built the first oncological centre in Russia in this format. You said that construction can be complicated, but in fact we built it in a Europe-like timeframe: it took us four years to open it. Now we treat patients, even young ones. The city helped a lot. I must say that this was only possible because Georgy Poltavchenko [St Petersburg governor] helped us personally in certain areas, where monopolists and other issues were concerned. Based on the decisions of Mr Poltavchenko and the city administration – because the money has been allocated to treat patients with oncology – all children who need this treatment will be treated at state expense starting this year. For example, today we have ten patients: eight are being treated at no cost and two are being prepared for treatment on St Petersburg’s account. Maybe it is possible to solve this problem at the federal level too? I know that such work is being done, but maybe it could be moved accelerated. Vladimir Putin: I have focused on this, even in my Address, but of course, we will allocate money for this. But these are specific decisions; they must be made by the Healthcare Ministry. We will allocate additional resources, but it is up to the ministry to decide how to use them, with specialists of course, taking into account that special attention must be paid to oncology. I hope your words will also be considered. Arcady Stolpner: If I may I would like to add something. In fact, there are few ill children, so this problem, in this narrow area, can be resolved with relatively little money. Vladimir Putin: We both know that when the state focuses on something specific, there will be certain results, and generally these are good results. Pediatric hematology/oncology can serve as the best example. How many patients were there before we opened the Rogachev Centre and how many are there now? Alexander Rumyantsev: Let me begin with what we have now. Today the survival rate in the Russian Federation is between 80 and 90 percent. These are people who get well after an oncological disease. Mr President, I would like to thank you for your support. You always say that you like us and check on us. I would like to say that this is a great responsibility for us. Vladimir Putin: Everyone likes a doctor, especially a good one. Alexander Rumyantsev: Yes, this is a big responsibility for us. We are trying to do everything we can, because the model we have implemented along with the Healthcare Ministry is important for every Russian region. We have 59 regions, along with Belarus, Kazakhstan, Uzbekistan and Armenia, that treat patients based on the same standard protocols and under the same financial conditions. These protocols are adjusted every year due to new discoveries in medicine. What were the reasons behind this success? We are talking about every child currently living in Russia. Thanks to the centre that was built under your supervision, which is now essentially ours, we have implemented a whole series of projects. This supports the full range of morphological examinations for children. The Healthcare Ministry helped us a lot by making sure that we receive funds to provide patients with the second, the so-called morphological examination. Which means that a child, who lives somewhere else, gets diagnosed, and we conduct a second examination at our institution in order to gather full information on the child. For the first time in Russia, we have implemented a rehabilitation project for children who survived cancer. It is an incredible project, which is giving us a lot of information about special methods of rehabilitation that every child who survived cancer needs. Last May, we opened the first ever centre for rehabilitation of infants who survived cancer. No other country has a centre like this. I would like to take this opportunity to say that these models, which we use to treat children, and we have about 4,500 new patients a year, can be used to treat adults as well. Cancer in adults is a major issue, because each year, there are almost 600,000 new adult cancer patients. This is a very broad programme, which you called a principal programme, and it really is principal for the development of the entire healthcare sphere, after the treatment of cardiovascular diseases. I also take this opportunity to invite you over. You have not visited us in a long while, and we would like to show you what we have done, show some things off, and, perhaps, discuss with you some matters related to the further pursuit of our cause. Our cause is to make every child healthy again. And we would like to show you how one can organise the work, the key component of which is love, love for children. Vladimir Putin: Are you creating a rehabilitation centre? Alexander Rumyantsev: Yes. It has been in operation for four years, the progress is slow, but I want to tell you: together with their parents, a total of 2,500 children from 85 Russian regions undergo treatment in this centre every day. It is an additional trip, since the centre is located outside the city, but I think that it is worth seeing, seeing how everything is organised. Vladimir Putin: It was not always easy with this centre: the issue of location, the issue of financing. Alexander Rumyantsev: But now it is. Vladimir Putin: Thank God that it is now, I am very happy about that. I will definitely come see it. Please. Yevgeny Shlyakhto: Mr President, I am probably expressing a common opinion when I thank you for supporting our professional community. I would like to draw your attention to the fact that you focused on patients in your Address. This is a key trend in our healthcare today. Our model of healthcare is patient-oriented; we are moving away from the model that focused on the doctor to a model centred on the patient. Everything should be tailored to patients and their individual circumstances. Second, I would like to mention the specifics of Russian healthcare. Close ties with scientific research are part of our tradition, and our goal is to make them permanent. I believe that the changes taking place in Russia today are the result of breakthrough developments in creating innovative medical technologies, diagnostics, and medicines. These changes are rapid, and everyone who comes to Russia sees and recognises them. We will have an edited T-lymphocyte a year from now. This is absolutely unparalleled technology. There are already pharmaceutical companies that work with research centres and universities and create new medicines. So, this is critically important. How can all of this be promoted in the Russian regions? The Healthcare Ministry decided (and we all support this decision) to create national medical research centres. Thank you for supporting this decision. This is not about someone being more important, and someone else being less important. We need to create a healthcare network for each region with account taken for its specifics, to identify the best practices in a region, to develop them and replicate the achievements that are currently available in the world. I believe that the role of national medical centres is to unite, help, and train staff, to develop and to promote innovative technology so it becomes readily available. So, thank you very much for the directive that you signed on the importance of training at research centres, we talked about this. Last, I believe that we have vast opportunities to develop digital healthcare. Vast. We already have many decision support systems in our country. This applies to hospitals, emergency care, and patients with severe disorders, especially in remote regions. I am sure that counselling will help significantly reduce mortality rates within the next year or two. We have reduced cardiovascular mortality by 35 percent. Everyone just cannot believe that this is true. I recently attended the spring summit of the European Society of Cardiology and told them about the 35 percent, and they cannot understand how it can be possible. “How did you achieve this figure?” they asked. We still have problems, but we should reduce it by another 30–40 percent in the coming years, and we will do it. Thank you. Vladimir Putin: We spoke about the centres today, when we inspected your centre. The Healthcare Ministry created 20 such centres throughout the territory of the Russian Federation. Where are they in the Far East? In Tomsk. Where else? Veronika Skvortsova: Tomsk, Khabarovsk, Vladivostok. Vladimir Putin: Khabarovsk, Vladivostok, Siberia and the whole European part. Today we already mentioned this; now we need to link all these centres. This is first. And second, it is necessary that these centres are connected with relevant institutions in the regions. We need to create a single medical complex so that, as you rightly said, your colleague in any, even a small clinic, has the opportunity to enter a specialised network, get advice, send data on patients for monitoring and treatment purposes. I am confident that this will play a very visible, serious role. We have been talking about the digitalisation of life in general, of the economy in all its manifestations and the various spheres of our life and activity, including healthcare. So, something is already happening here, it is already noticeable, but it is not enough. We will develop a separate programme for the digitalisation of healthcare. As far as I know, the Ministry has already prepared an additional draft resolution, which will be directly related to this type of activity. We just need to speed up its adoption. Is it already with the Government or still with the Ministry? Veronika Skvortsova: By April 1, it will be considered in the Government. Vladimir Putin: So, the project has been developed and will be released in April. Veronika Skvortsova: Yes. Vladimir Putin: Please. Vladimir Goryachev: Can I say a few words? I would like to continue with childhood cardiology. Vladimir Goryachev, head doctor of the Samara Regional Clinical Cardiology Centre. I must add that 12 years ago we created a system of organised help for children with congenital heart defects at our centre. Over the succeeding five or six years the waiting list for these procedures all but disappeared. We had a history of participation in various state programmes dedicated to motherhood and childhood. I am afraid that without these programmes we would not have been able to reach this level of medical support. Today we operate on almost all children’s congenital heart defects, including new-borns with defects that were considered fatal not long ago. Now it is clear that survival is possible with 95 percent of them. I believe that we would have overcome these difficulties one way or another, but the existing programmes included additional financing, additional equipment and personnel training so we reached this level with fewer losses and in a shorter time, let me put it that way. We continue to feel your concern. Thank you very much for this. This is clear because I believe a society’s maturity is determined by how it regards its most vulnerable people: children and seniors. Primarily children, or course, because they are our future. Today we have a large programme to update polyclinics for children; let’s hope this will continue. Thank you very much, not from me of course, I am just the messenger, but from the entire paediatric community in Russia. Vladimir Putin: Thank you. Mr Goryachev, we have really done something, especially at these centres; we have already talked about several other children’s centres. This is a great level; it is really something to be proud of. It is not by chance that we are allocating an additional 10 billion each year, starting with this one, for children’s healthcare, because the situation at local children’s polyclinics and hospitals is, to put it mildly, far from perfect. By the way, this is why we must continue supporting the large centres regularly as this money is distributed (this is additional money), because we are proud of them and they must become a methodological base for developing children’s healthcare. Among other things, and maybe most importantly, we are allocating 10 billion rubles to raise the level of children’s healthcare in municipalities, at polyclinics, hospitals and paediatric departments at general hospitals. I would like to focus on this. Now we must take the next step: expand the opportunities we have in children’s healthcare today. Please, go ahead. President of the National Medical Chamber Leonid Roshal: Mr President, many thanks for convening this meeting and, in general, for much of what you have actually done for our healthcare. During our most recent meeting, you promised to increase funding for healthcare. I am pleased to note that your actions are as good as your words, and everything is going well. What you did – achieving incrementally 5 percent of GDP for healthcare needs by 2025 – is nothing short of great. We have discussed these issues with you. This is our longstanding dream. Without this, a breakthrough in healthcare can hardly be expected. Of course, we need to use this money wisely. We did not forget that it was your decision to completely re-equip healthcare facilities in Russia, which was effectively accomplished. Notably, we like to exceed our target plans, and not just with regard to the Crimean Bridge. It was nice. We will not object if you have the chance to exceed the target figures for healthcare financing in the future. We don’t want it to look like you offer a finger and we bite off your hand. We are talking based on reality. I am convinced that we are treating patients better every year, and the equipment is better, but the number of complaints increases. Frankly, this is not the case just in our country, but worldwide. Complaints about healthcare are on the rise in Germany, Great Britain, and the United States. This is because today the demands are high, off the chart occasionally. The number of complaints and criminal cases is increasing, I believe, artificially, not because we are treating our patients worse: we are treating them better every year, but the media instigates. (Leonid Roshal went on to discuss specific issues related, in particular, to medical mistakes and legal issues, staff shortages and safety of medical workers.) Along with the Healthcare Ministry, we are overhauling the training system. This is something we can really make happen. The requirements for higher education are getting tougher. We believe that doctors must engage in lifelong learning, which has never been the case in Russia. We are introducing a continuous medical training system, which should be convenient and free for doctors. We are working on professional standards and compliance with education standards; occupational clearance, which is also new for us; new approaches to performance reviews and assignment of qualification grades; and the development of clinical recommendations for treatment protocols. The National Medical Chamber has already assumed responsibility for these areas of work. Even though with the difficulties, the public-private form of managing professional healthcare is being introduced with a gradual transition to self-regulation, and we are grateful to you for supporting these undertakings. We have found common language with patient organisations. We invite them, they invite us, and we pursue the same goals. Mr President, we clearly see our challenges and know how to overcome them. I am confident that we will see to it that the people of Russia are satisfied with healthcare and doctors. Vladimir Putin: Indeed, the National Medical Chamber is an accomplished entity, congratulations, because this project is your brainchild in the broadest sense of the word. The concerns expressed by the officials of the Healthcare Ministry and its regional structures, never came true. The National Medical Chamber has become part of life and is playing an essential part as an indicator of the quality of work and protects the interests of medical workers. You mentioned this as well and expressed your concerns. I will go over them briefly. Transferring certain functions from state entities to such an authoritative non-profit organisation as the Medical Chamber is, of course, an important area of developing the National Medical Chamber. As we have already discussed, we will need to follow this path gradually as solutions to these and other issues become available. I support this. Now a few words about increasing the funding for healthcare. There is no need to curse anyone, there are no enemies here and in general there are no enemies of healthcare in the Government, including the Finance Ministry, as I have said more than once. It’s a matter of counting. If you add up healthcare funding from all sources it is over 5 percent. This is the problem. It depends on how you count it. It is simply necessary to make sure that my colleagues in the Government and all of us understand what this is about. Regarding pure budget funding, it will be much less. Some analysts believe it was 3.2 percent last year. Remark: 3.3. Vladimir Putin: I will not go into details now. Believe me, we have fought and argued over all of these issues so much. What would I like to assure you of? We will do everything we can for the funding of healthcare to be real rather than on paper. We realise how important this is and will do all we can to use even additional funds – and they are already appearing – to spend part of these additional funds on resolving healthcare problems. I said in the Address that this is a priority area, not just for effect, not to please those that need medical care or the medical community. We really believe, and I personally believe, that this is one of the most important areas of national development. We will do this by any means possible. Now a few words about growing requirements. This is always the case. Do not get mad at anyone. This is always so. When there is nothing, everything is okay. But when things start moving and something is developing, as soon as people begin to understand that there is a different life and different opportunities, they immediately look not at what they had yesterday – this is quickly forgotten – but at what they can get tomorrow. These are the lawful requirements of the people, and we should be guided by these legal requirements. You said that some specialized questionable companies, even legal ones, are emerging and extorting money from the healthcare system and medical workers. Regrettably, this is the negative side of any process that is being funded in a systematic way. As soon as money appears somewhere, parasite companies emerge and try to take a bite of the money in one way or another. But we must counter this. We will pay attention to this and try to prevent anything like this from happening. Naturally, the security of medical workers should be ensured and responsibility for damages increased. We will see how the latest decisions will work in practice and will toughen the requirements if necessary, as well as prosecution for attacks on medical workers in any form. A few words about the Accounts Chamber. The Accounts Chamber is designed to analyse the efficiency of government spending, spending budget funds, federal funds in the first place. It does not make final decisions but only keeps us informed. Decisions are made by other instances that have an opportunity to assess objectively the information they get from the Accounts Chamber. So, there should be no serious apprehensions in this respect. Go ahead please. Oleg Karpov: Oleg Karpov, director of the Pirogov Centre. Mr President, thank you very much for your words of gratitude to medical workers for which you found room in your Address to the Federal Assembly. We hear them and this is very important for us. We, everyone here, remembers the 1990s and what life was like then – regrettably, it was difficult to survive at that time. We were essentially craftsmen and saved our patients only by resorting to art and intellect. Everything has changed since the 2000s. And indeed, returning to your Address again, by adopting systematic and consistent measures and facing the problems of the industry, you took us into the orbit of technological development that allowed Russian healthcare to match European and world standards. This is true. Today we treat three to four times more patients on the same number of beds and the number of operations has increased as much. Today we treat our patients as we could not before and receive results that seemed fantastic 12 or 15 years ago. These are not just words. Here is a fact. Our centre is well developed and famous. In the early 2000s there was a pool of patients who came to us for final tests and then went abroad for medical treatment at their own expense. In a few years – and this evokes an unusual feeling of pride and joy – these patients stopped leaving. They stopped leaving because now the latest medical aid, all technology is available in Russia – the same equipment, the same standards and the same medicines. Yes, there are some exclusive medicines or equipment in some places, but they will become available. Inbound tourism is important in this respect. In our industry we have tens of thousands of patients in the federal centres alone. These are major financial injections. Our industry received about 16 billion rubles in 2016. About 3,000 foreign patients have come to our centre in two years, including 750 that arrived to be treated for multiple sclerosis. We developed our own technology for such treatment and received license for it. It is being used in several places in the world. Patients from the United States, Canada, Norway, France and Spain come to us and wait for treatment with this technology. This is a very good resource, for our earnings as well. I believe against this rapid increase in economic efficiency we should not forget that the moral and ethical factor of communication between the doctor and the patient, the medical worker and the patient also remains a priority. By tradition this was inherent in our domestic healthcare. The human factor has always played a special role and we consistently pay attention to it. And, finally, one more point, Mr President. You said in your Address that financial allocations are required for us to keep up with this rate of technological development. We are talking about this today. This is certainly the case, but probably apart from efficient government spending broader use must be made of private funds and this is what we are doing. (Oleg Karpov went on to describe the public-private partnership at the Pirogov Centre.) Now departments are jointly and actively working through public-private partnerships. We would like to ask you to keep these issues under your personal control so that they are duly completed, and we will start consistent and confident work in these areas. And the last point. Naturally, it is indicative that you are meeting with us, medical workers in the last hours of such a complicated political time. Thank you for keeping us a priority as before. Vladimir Putin: Thank you. I mentioned my recent meeting with transport workers, the agro-industrial complex, and earlier with researchers and educators. That's why our meeting is more like a staff meeting, but of course, a special one, bearing in mind that we need to articulate our goals for the next six years. So, I am sincerely saying that, of course, we constantly discuss this with the Minister and the Deputy Prime Minister who are present, and the Prime Minister and our colleagues from other ministries and departments. We do argue a lot, but listening to people who do things with their own hands is particularly valuable. That is why I meet with representatives from various industries. Of course, we must follow our domestic political schedule, but we just need to formulate our goals for the next six years. I hope – and it turns out that way – that we are talking about what we believe are the most important, interesting, promising and essential things that need to be done. You mentioned public-private partnership. Of course, this must be promoted. However, we should not forget that we must use a certain set of tools to make sure that people can have access to free medical care in our country. This is a legal requirement, and we must follow it. At the same time, of course, it is necessary to develop all alternatives, including public-private partnerships. Of course, private investors expect a return on their investment. In this regard, I fully agree with you that inbound medical tourism is extremely interesting and important, including to improve the well-being of those who work in the medical industry. The international medical tourism market is estimated at about $10.5 billion. In 2016, Russia accounted for only $250 million despite your findings; $10.5 billion was in 2016, now it is probably more. And we had just $250 million coming our way. By the way, our possibilities for this are vast. This will grow if we will act purposefully in this area. It will definitely help not only those who come for medical help to Russia from abroad, but it will also raise the overall level of our healthcare, because the standards will be fairly high. In this regard, it is important for us not only to provide high quality medical care, but to also promote rehabilitation services. We are still behind your colleagues in this area, that is why centres such as the Dima Rogachev Centre and others are making a point of this issue. Are you also contemplating a rehabilitation centre? This is critically important. This is important for your potential patients and medical tourists, both future and current. If you want them to come, you need to figure this out, but, of course, do not forget about the core activity – medical care. Now I want to get back to finance issues in general. I already mentioned it earlier, and we will definitely focus on this, not just focus, but allocate additional resources. Your ideas on public-private partnership should in no way replace state funding, but they will complement the general efforts of the state to promote healthcare. Ivan Stilidi: Mr President, I am Ivan Stilidi, acting Head of the Blokhin Russian Cancer Research Centre. I would like the words of gratitude to be more pronounced. They are from all those involved in oncology. Thank you very much for seeing that oncology has been included on the list of priority areas of the development in medicine, and in general, the state is paying much attention to it. I must say we were ready for this because everyone in the professional community who has devoted years of their life, their mind and soul is always waiting for their cause to be a priority. In this sense, oncologists have lived to see this. We were also ready for this because the full modernisation of oncological institutions began in 2009 and these steps have already produced results. Some of my colleagues are here. They are directors at national oncology centres: Andrei Kaprin from the Hertzen Centre and Alexei Belyayev from the Petrov Institute. And, of course we are now working with the fresh impetus that you have given us on developing a national anticancer programme and building a fundamental federal anticancer service. Naturally, together, we are a powerful force. I believe this new impetus should produce results. Once again thank you very much on behalf of all oncologists. Vladimir Putin: Thank you for recalling the past decisions on consolidating oncology centres and early treatment clinics. It is, of course, a pleasure to hear that you felt that at least something has been done there and that you see results. As we agreed, we will take the next step by all means possible. I have already determined this as a priority and we will work together on it. Sergei Boitsov: Sergei Boitsov, Director of the Russian National Medical Research Center of Cardiology and at the same time chief visiting specialist of the Healthcare Ministry on preventive medicine. I would like to speak primarily about preventive medicine and issues in primary care. This is what I will start with, since the issue of accessibility in this regard is most urgent. In the past three months alone, you have addressed this issue twice – during your news conference and in your Address to the Federal Assembly. The problem began to develop in the early 2000s, not now. At that time there were 43,000 first aid/obstetric stations, now there are 36,000 stations but the reduction took place in the first years of this century. In the past few years, the Healthcare Ministry tried to restore the balance and opened almost 900 stations in the last two years alone. But now we are receiving a powerful additional impetus and thank you very much Mr President – the Government of the Russian Federation has issued a resolution on making a significant financial injection of 1.2 billion on these stations alone. We have confidence that in two years or in two and a half years at most the problems will be resolved – of course, with the participation of the regions. No less important is the matter of mobile stations. They are needed for 1.7 million people in 65 regions. The number of stations is growing at a good pace: there were 1,400 mobile stations four years ago and now there are 3,500. But at least 1,800 are still needed. There has also been a financial injection of 2.2 billion. It will be possible to launch about 200 stations this year. So, thank you very much for your special attention to this issue. Another issue, which you also mentioned in your Address to the Federal Assembly, is preventive medical examinations. In 2012, the country resumed the regular large-scale system of preventive medical check-ups for the adult population. Originally, it was organised every three years. This year, we are launching a parallel campaign of oncological screening every two years. This involves preventive examinations and health centres. In total, 36 million adults have medical check-ups annually. This is not only detection of diseases and risk factors but also promoting a healthy life style, which we call our number one goal. Children as well, over 30 million children get medical check-ups annually. This also promotes a healthy life style. I would like to thank you again for your special attention to this issue. We have two requests. The first one concerns promoting the law on salt iodisation. This is a very important issue for our country. 113 countries have already adopted the salt iodisation law. This not only prevents thyroid diseases but also solves intellectual development problems. At least 15–20 percent of our population lives in iodine deficiency zones. We consume three times less iodine in Russia than necessary. At the initiative and with the active participation of academician Ivan Dedov, the Ministry of Healthcare has submitted a supplement to the law on food quality and safety. We are asking for your support, Mr President, because we do not rule out difficulty in passing this law. Similarly, a hard road lies ahead of another document, which is not a law but a strategy for promoting a healthy life style and preventing and controlling non-contagious diseases. This document involves a large number of participants, such as agencies, services, public organisations and so on, all of them having many interests. This document is also passing through several departments with difficulty. We need support here as well. Thank you very much. Vladimir Putin: Yes, everything you said is very important. I do not even know what to focus on. Prevention of non-contagious diseases. We have addressed this issue already. I know about the internal difficulties, all these traps and pitfalls, we will tackle them by all means. I agree with you, this is a very important area. As for the law or decision on iodised salt, Mr Dedov is handling this, promoting it as a person who has been working in this area all his life. This idea did not com about yesterday. We prepared a bill in 2013, but it was actually blocked due to the position of our industry that it would considerably raise the cost of production. I agree with you that we should follow up on this issue by all means. Indeed, we have a lot of regions situated quite far away from the sea and people need this. I believe that such programmes were in force and all this was produced in the USSR. We should follow up on this issue by all means because, what can I say, Mr Dedov raises these issues for good reason. This does not only concern the thyroid gland, but people’s overall health. So we will follow up on this. Good that you remembered about it. Concerning the promotion of a healthy lifestyle. This is crucial. I agree with our colleagues who say it is time to organise this in such a way that it would do more than just encourage people to take up fitness and sport – every individual is responsible for their health. That is how things are in the rest of the world. We need to steadily, easily in terms of finance build up a system that will increase peoples’ responsibility for their own health. This is the next point that you took notice of. I find it important. Next, concerning preventive screenings. You know, I do not intend to go into detail, I also mentioned in the Address that it is necessary to initiate a system of preventive screenings. We even argued about the proper term and finally agreed on exactly this phrase – preventive screening, and not something else, not “annual medical examination.” I will not go into detail; I believe you understand what this is about. But there is a difference between annual medical examination and preventive screening. Anyway, it is not that important what we call it. What is important is a different matter – what would happen next? So, if they diagnose something, what comes next? The system must be ready to respond to identified problems. And this is a different story, different funds. What does different mean? It is the healthcare system. Mr Roshal raised this point; he always raises questions of funding whenever we meet, I am even scared of him because he always brings up money. I mentioned rural and mobile health stations. We can estimate how much that costs. Not only can we count, it has already been calculated. We know how much it costs today. We know how much the informatisation and digitalisation of medicine will cost. These are accounting items, and it is all there – we will need to allocate this much in the following years to this and that. And what other things do we have funding for? This is actually professional analysis with the need to determine the top priorities at this time. You mentioned the primary level in healthcare. We funded it in due time hoping that just like with the primary level in education it would be taken on by the regions. However, this did not happen in a lot of cases. We have to go back to that again and allocate funds from the federal budget. We have to build a system of preserving the achieved level and of improving this situation in the future. These are the things to work on. All the issues you have raised are important and interesting; we will certainly be working hard on them, including the law on iodised salt. This is not a side issue, I agree with you. Please, go ahead. Ildar Khairullin: I am Ildar Khairullin, Chief Doctor at the Republic’s Oncology Clinic, in Kazan. Mr President, six years ago, in February 2012 you visited the Emergency Clinic in Naberezhnye Chelny and set a goal for this clinic to become one of Russia’s best. I can now report to you that in 2015 the clinic passed international accreditation of patient safety quality and is the first and only state clinic in Russia with a JCI standard rating. Currently, I work at the oncology clinic. Your Address set out an undoubtedly very ambitious and interesting challenge to enter the 80+ Club. And you immediately offered a solution – annual preventive screenings and proposed a national oncology programme. Undoubtedly, cancer treatment today drives healthcare development and presents a consistent approach, from the early diagnosis of malignant tumours, work within the primary network, specialist high-tech medical aid, rehabilitation and palliative care. We have everything here, and this expertise can be applied to other medical services and other non-infectious diseases. (I. Khairullin went on to speak about the oncological medical services in Tatarstan, specifically about annual medical examinations). We are grateful to the Health Ministry and Ms. Skvortsova for last year’s resolution, and we noticed the results this year in the increased funding for chemotherapy. This year, inpatient clinics received an extra 275 million roubles, which allowed us to introduce innovative chemotherapy medication in the key areas. At the same time, we are fully aware of the fact that rates for chemotherapy medication are growing steadily, new innovative target and immunity drug therapy is being developed. But the rates are unfortunately lagging behind the cost of this medication. Therefore, we need to ask you to speed up the development of domestic innovative target chemotherapy and radiotherapy medication. On the other hand, we would like you to set up an agency that would evaluate the financial efficiency of introducing a certain type of treatment or medication in terms of cost and productivity. Radiology is definitely an effective therapy for our cancer patients. This method is the most effective in terms of cost and efficiency. Nearly 50 percent of cancer patients require radiology treatment. I know that many regions have difficulties in this area. The number of radiology units and linear accelerators is still below international standards. Therefore, I would like to ask you to intensify the work to develop domestic radiology equipment, linear accelerators and replace the expensive heavy medical and diagnostic equipment in accordance with the technological cycle as part of the cancer treatment programme. These measures will definitely help achieve the targets you set in your annual Address. Vladimir Putin: Thank you. First, I would like to congratulate you on your results. These are your achievements and the achievements of your employees, and they are inspiring. We should make the most of our best practices, both in your republic and the rest of Russia. As for the specific issues you raised, the first thing we should do is review the preventive medicine data. The best way to do this is by addressing another objective first, we talked about this, digitisation and informatisation, and then it will all fall into place. That is the programme we intend to invest in. As I have just said, everything can be calculated. Believe me, we have calculated up to tens of thousands how much it will cost to implement this country-wide. We will deal with that. That was my first point. Secondly, a few words about efficient medicines and techniques. As far as I know, the Healthcare Ministry has an Expert Council. In general, medicine has become so complicated today – it is not simply breaking a pill in half and giving one to a patient for a headache and the other for stomach pain relief. We have walked around here and seen things that are directly related to the most complicated areas of science in different disciplines. Your branch is science-intensive, probably, the most science-intensive branch. Therefore, only specialists can determine what is effective and what is not. There is the Expert Council. The only thing I could probably ask the Minister is to include practicing specialists on the Expert Council. Veronika Skvortsova: Mr President, we established a special federal centre that does independent expert reviews on all areas of pharmaceutical and clinical economic effectiveness. It has been operating for the last year and a half. Mr Khairullin, we invite you to attend the council at this centre and see for yourself how all this is already working. Vladimir Putin: Ms Skvortsova, I think it may not be enough to just invite one colleague. It might be necessary to invite not only practicing experts from Tatarstan, but maybe from other clinics as well. We need to see, three or four specialists may well be included. Veronika Skvortsova: All right. Certainly. Vladimir Putin: Now a few words about domestic equipment, especially heavy equipment. We know that it is appearing, that it exists in principle. But it is perfectly obvious that the range of available equipment must be much broader. It takes a long time to develop and produce such equipment. So we are facing this task in principle. Let us get it up to date. Of course, even after our current meeting it is possible, if necessary, to formulate relevant instructions to the Government as a whole, to the Healthcare Ministry and the Ministry of Industry to be more active in their joint work than they have been so far. But I completely agree with you that we must have our own, effective, modern and promising equipment. Go ahead, please. Yury Zhulyov: Mr President, thank you so much. Let me introduce myself. I am co-Chairman of the National Patients’ Union and President of the National Hemophilia Society. My name is Yury Zhulyov. I am sorry I was so adamant in asking to be given the floor, but I am the only representative of the patient community at this table and, of course, I would like to express a number of considerations and important positions. Vladimir Putin: It is a shame but I did not know we had a patient community. Yury Zhulyov: I am glad that you know about it now and in conclusion I would like to mention again one very important undertaking that we are doing together with our colleagues. It would be strange if I did not talk about the patient-oriented model of healthcare. Incidentally, as a lawyer I would like to say that in the future we should probably pass a law on this position. There are two very important points that we are concerned about. First, this is really a view of the patient as the centre of the healthcare system, the consistency of rendering aid to a patient, starting with diagnostics and ending with rehabilitation – you were absolutely right to speak about rehabilitation problems. This is the gap between institutions, different types of aid, including the organisation of aid and routing inside a medical institution as such. I think now the Healthcare Ministry is actively and properly promoting the project “Prudent Outpatient Clinic” whereby patients feel the constant attention of medical workers and understand the step-by-step rendering of medical care. The second part is crucial. You know that technology is very important, but medicines are equally important. I would like to point out a humanitarian aspect, that is, the doctor-patient relationship. It is a central part of healthcare. To me, patient-focused care is not just a phrase or a term, but something that must be complemented with practical principles. One such principle is the doctor-patient relationship. We must move away from the boss-subordinate principle of relations to dialogue and partnership. This principle involves two very important things. First, the huge funds we invest in healthcare cannot attain their goal because patients are not fully aware of their role. Patients must have the necessary information and act as partners in the process of medical treatment. They must know the elements of the proposed treatment and its goals, as well as their role in this process. This will greatly enhance the efficiency of medical assistance. Second, the doctor must have the instruments for preventing conflicts and must have the skills of doctor-patient communication. We believe that ethical and communication aspects have been eroded in the current process of medical education. We propose that the principles of deontological ethics and doctor-patient communication be added to the mandatory educational standards. This is extremely important, because this is what we lack now. Once again, this is not just my personal opinion. I promised to conclude my report by telling you about an important annual event that the Russian Patients Association holds together with the Healthcare Ministry. It is a very important event, which Ms Skvortsova has never missed. I am referring to the Russian Congress of Patients, which is attended by delegates from the National Medical Chamber and Mr Roshal, the Civic Chamber and the Russian Popular Front. I believe that our congress is a very good platform for dialogue between the authorities, public associations, civil society and patients, a platform where we also discuss the difficult issues I have mentioned. I would like to say that in my opinion, apart from what we are discussing today, the enhanced skills of our doctors would enhance the quality of medical assistance. In conclusion, I would like to thank you because we do feel that the state is giving priority attention to healthcare, which is a state priority. The proposals you have put forth in your Address are not just fine words but a matter of life and death for many people. We look forward to seeing these proposals implemented, because we know that although much has been done we must keep moving forward to find solutions to very serious problems. Vladimir Putin: Thank you for all your work. I agree with you that we should give our attention to these things. And then we will probably not see any conflicts such as Mr Roshal mentioned. However, we must not lay all the blame on one of the parties. What we need is modern and efficient doctor-patient communication. This is certainly very important, and merely reading out the Hippocratic Oath is not enough. What we need is systemic work. We must discuss this with the Healthcare Ministry and probably also with the National Medical Chamber. It is one of the areas where we must work. I remember Mr Roshal speaking about this when he told me about the idea of a medical chamber. Leonid Roshal: Yes, it is very important to introduce conflictology both for doctors and for patients. The National Medical Chamber is working in this sphere. Vladimir Putin: This issue was raised at the very beginning, when Mr Roshal told me about the idea of creating the National Medical Chamber – he also spoke about this issue then. Please. Andrei Kaprin: Mr President, I am an oncologist, head of the National Medical Research Institute of Radiology, which includes one of Europe’s oldest institutes, the Pyotr Hertzen Institute. And I, of course, want to thank you for the attention you have been paying to oncology and for the development directions you have given us. It was a very interesting decision, implemented by the Healthcare Ministry led by Ms Skvortsova, to merge several centres into one. This association has been operating for about five years and includes the oldest institute in central Moscow and at the same time a huge institute in Obninsk. It is equipped with cutting-edge radiological equipment. Naturally, we would not be able to open such a facility as the one in Obninsk in Moscow or build similar ones in the regions. The Ministry of Industry and Trade is helping us build a centre for pre-clinical studies of new radionuclides and a line of targeted medicinal radio compounds, which our nuclear power also needs. So, we are grateful and we want to take part in such large associations, which allow us to not spend additional money on expensive equipment. For instance, we have the CyberKnife which costs 500 million rubles, and the Gamma Knife, which costs 300 million rubles. But they are not so popular that we need them everywhere. So, I want to thank you for such a sensible and careful attitude to cancer treatment and the related expenses. We are ready to continue developing our own equipment. Vladimir Putin: As for Obninsk, the decision to establish such a centre was a well-thought-out one, I mean the capacities you mentioned. Of course, in this sense, Obninsk has a huge competitive advantage, and you are making full use of it. I wish you further success. Naturally, we will support everything that was done in Obninsk and the idea of such centres. Please. Nikolai Daikhes: Thank you, Mr President. I would like to thank and support our colleagues from the patient community, because there is the issue of providing high-tech medical assistance to people with disabilities, and we are working on it now. My name is Nikolai Daikhes, I am the director of the Federal Centre of Otorhinolaryngology. We appreciate that we can speak now, for not always do narrow specialists (we do not like this term, however) have the opportunity to speak alongside oncologists and cardiologists. Last year, we performed Russia’s first bionic eye implant surgery on a patient who was completely blind. We reported on that, and you supported us then. There are several such first surgeries in the world, and Russia is in the lead. Naturally, it is very important that we combine this method with the already known method of cochlear implant surgery, which provides a sense of sound to people who are profoundly deaf. It especially concerns children. Vladimir Putin: Does it have to be performed at a very early age? Nikolai Daikhes: Preferably.And, of course, in Russia we have made a breakthrough, I will say a few words about it… Vladimir Putin: Sometime before the age of three? Nikolai Daikhes: Before theage of three, so thatthe child will not become deaf-mute. But it is helpful to adults too. When we make advances, we must not deprive them of such an opportunity. I mentioned people with disabilities because there are millions of people with impaired hearing and sight in Russia, and these technologies provide us with unique opportunities. The most important thing is that we can now help deaf-blind people, to whom you also provide social assistance. You are doing a lot for them, we know it. Of course, such opportunities arise here. In general, restoring impaired sensory functions is one of the most important breakthrough technologies of the 21st century medicine. And, of course, the fact that today Russia is a leader in this area – in restoring both the sight and the hearing – is a reason to rejoice. However, we regard the development of the Russian production base for such devices as our important task. We believe that we need a state programme or maybe your order to promote our cooperation with the medical industry in creating high-tech methods. Perhaps we need to create a cluster. Today we have spoken a lot about establishing large centres. We opened a centre three years ago. It is the largest centre for otorhinolaryngology and head and neck surgery in Europe and the world. Of course, we cannot compete with academician Yevgeny Shlyakhto, but it looks rather good all the same. We have branches in Khabarovsk and Astrakhan, where people receive high-tech treatment in these areas, and they do not have to go to Moscow for this. We believe it is very important for developing federal centres. (Then Nikolai Daikhes spoke about R&D cooperation with the industry.) As a member of the Russian Civic Chamber, I can say on behalf of my colleagues, not only doctors but all of them, that the next Civic Chamber forum (this year we have seven, and you will attend the final one, where we will present a report) is dedicated to the healthy way of life. There are two issues related to the patient community and all our public organisations, because they are also involved in this: oncology and inbound medical tourism, which we have spoken about today. This is also very important for us, and we will present this in the final Civic Chamber report at the end of the year. Thank you, Mr President. Vladimir Putin: I would like to congratulate you on the level you have reached and thank you for the results of your work. Please pass on my best regards to all your colleagues. As for the equipment, yes, we have talked about it, but we need the Healthcare Ministry together with the corresponding agencies and the Government, first of all the Industry Ministry, to take care of this. I will take note of this, and following our meeting, we will issue a corresponding instruction, among other things. What is important here? A lot of our enterprises are basically ready. They have even set such targets, especially defence industry enterprises that have the necessary equipment and well-trained personnel. You probably saw the second part of my Address to the Federal Assembly, which was devoted to defence. Why do we have those capabilities? We have re-equipped defence industry enterprises, investing almost three trillion rubles in recent years. Otherwise, it would have been impossible to achieve this, there would have been no equipment, but we have it as well as the personnel. What must we ensure? This is the Healthcare Ministry’s task: the consumer market. The defence industry’s task is to diversify production and gradually reach the level of at least 50 percent civil production in the near future. Some enterprises are already producing 20 to 30 percent, but we must reach at least 50 percent and even more when defence procurement goes down. Everybody is interested in this. They must have a market, because sometimes they complain that they are ready to produce this or that equipment, but nobody buys it because they prefer foreign versions. Nikolai Daikhes: Mr President, I have noted, and you heard me, that we need close cooperation. We can tell them what we need, and when we order what the institute needs and they make it, we will buy it automatically; we will do it for ourselves. Vladimir Putin: Excellent. You are right. Thank you very much for raising this issue. Let’s work on this. Everybody is interested in this, so let us work harder. Yury Lobzin: Mr President, I am a doctor treating infectious diseases, and I cannot help but say a few words about infectious diseases because we have discussed all issues here, including cancer treatment and cardiovascular diseases. All of them are very important, but we cannot forget about infectious diseases. I head the Children’s Clinical Research Centre of Infectious Diseases. I would like to thank you very much on behalf of the Centre’s employees and all doctors treating infectious diseases in children and adults. The Institute of Child Infections was eking out a miserable existence six years ago, with its buildings dating back to 1901–1902. You signed the Federal Targeted Investment Programme. Today, our Centre has turned into a modern European-class and, maybe, even world-class organisation. Its area has more than tripled from 10,000 to 36,000 square metres. The Centre’s modern expert-class systems account for 98 percent of its equipment. We provide wonderful opportunities for patients, and we treat children inside individual Meltzer boxes. We can say proudly that this is a truly modern and efficient centre. This is important for the entire country because it is the only leading centre that trains doctors from other regions. Today, we have obtained very serious results in etiological decoding and antibiotic resistance. This task has global, rather than just national, significance. I would like to thank Ms Skvortsova for attending the celebrations of our institute’s 90th anniversary last year. In her report at the World Health Assembly, she even cited research papers of the centre’s experts. Second, we are now saving children who could not be saved in the past. This year alone, we treated 17 children with extremely serious cases of meningococcal infection, acute meningitis and encephalitis with severe brain damage, and we saved 15 of them. In the past, children with acute Waterhouse-Friderichsen syndrome succumbed to the disease. Rehabilitation is the third issue. This complex has managed to preserve all three aspects, including diagnostics, intensive therapy and the rehabilitation system. Russian-made equipment accounts for 60 percent of our up-to-date equipment making it possible to restore children’s locomotor and mental functions within two months, rather than 12 to 18 months as before. Ms Skvortsova has seen such children, including a completely paralysed 12-year-old girl from Crimea. She walked away from us two months later, and she even danced before us in gratitude. Mr President, our centre now trains Russian and foreign doctors, and this is a major achievement. Eighteen months after renovation, the centre has already trained 400 doctors from other countries, and this number is quite substantial. Dr Carissa F. Etienne, Director of the Pan American Health Organisation of the World Health Organisation, visited us and asked whether she could come here more often. She said she liked our centre and noted its impressive level. Therefore, we have every reason to feel proud. Thank you once again for adopting the programme at that time. They told me that it was easier to shut down our centre than to renovate it. But it is impossible to shut it down because this is the only leading national centre that charts the strategy for treating children’s infections. There is another painful moment, if I may. Of course, this is all good, but it would be better if children did not get infections at all. Unfortunately, 85 percent of all diseases are childhood illnesses. And children die – about 50 percent of all deaths are also due to infections, and probably 25 to 30 percent of infections result in disability. In this regard, a painful issue is vaccines for prevention, which also ensure the security of our country. Vladimir Putin: Is this prevention effective in the case of infectious diseases? Yury Lobzin: Absolutely. Here’s the latest case: a dad came to the patient community – his daughter was saved from a meningococcal infection – and said: if I knew that it was possible to prevent this grave illness, when she was between life and death for two weeks, with a single vaccine, of course, I would have done it and I should have done it. But here there are problems. Vladimir Putin: But now some people prefer to avoid vaccination… Yury Lobzin: Unfortunately, Mr President, there is an anti-vaccine trend. I do not know who promotes it, where it comes from, because we have a lot of resistance against vaccinations, so if it was regulated on a national scale, it would be great. Vladimir Putin: In some countries, children are not admitted to preschools, kindergartens without vaccinations. Yury Lobzin: Yes. Yury Zhulev: Mr President, we, as the patient community, do oppose these trends. Vladimir Putin: Which trends? Yury Zhulev: When parents refuse to vaccinate their children. They endanger the lives of their children. Vladimir Putin: They endanger the lives of their own children and also other children at a school or kindergarten. Yury Zhulev: Of course, and also other children. Therefore, our Russian Patients Association is in solidarity with the Healthcare Ministry, with specialists. Everywhere, where possible, we talk about our attitude to this process. This is really a matter of security throughout the country and specific children. It is outrageous. Vladimir Putin: You raised a very important issue. And to address it, of course, we cannot use more rigid methods, some administrative orders. We badly need the interaction between specialists and public organisations. And I am very grateful to you for this. This, of course, is subject to discussion. Some administrative decisions may also be adopted. We just need to do this carefully, without administrative shouting and commands. But we need to explain it to people what are the potential results of their behaviour, what it can lead to. After all, this is always a very difficult choice, especially when it comes to children. There are examples where these vaccinations lead to adverse consequences, so we need to work carefully with people. Thank you for raising the issue. Yegor Korchagin: Mr President, I represent a large regional Siberian healthcare centre: the regional clinical hospital in Krasnoyarsk. I am the head doctor, Yegor Korchagin. We are very happy that our hospital got lucky with the upcoming 2019 Universiade and we will build an advanced surgery wing. This will create entirely new conditions for treating our patients. These include patients with burns, cardiac diseases and organ transplants. To tell the truth, this will bring medical help in our country to a new level. The hospital is to open on the eve of the Universiade. I am sure that the day when we will open this advanced wing in our city together with you is not too far off. I would like to focus on two issues that have not been discussed today. First, as Mr Roshal said, recently we received a large number of complaints, including those in the media, for allegedly poor quality medical help. In addition, there is an opinion that healthcare workers are overworked. I think there are two aspects to solving this problem: medical and sociopsycological. The first one has to do with the fact that advanced medical technology must be based on clinical recommendations designed by specialists based on tests that prove the effectiveness of these approaches. It is clear that many things in medicine depend on experience today and maybe on the readiness to tackle tasks in an unconventional way. I am absolutely certain that before doing something creative we must implement the mandatory programme, I mean comply with the procedures adopted by the medical community. The procedure for providing medical help and treatment protocols in concrete hospitals must be drafted based on these clinical recommendations. We know that Ms Skvortsova’s colleagues have drafted a document amending federal legislation and approving standard approaches to developing clinical recommendations, and I would like to ask you to approve this document in the near future. I think it would benefit the entire medical community. The second aspect of this issue is related to the things the representatives of the Civic Chamber and the patients’ community have already said. However, I am not only talking about the doctor–patient problem. There are many people working in healthcare who are not doctors, and just one rude word from a guard or a clerk can destroy all the titanic work done to save patients. I believe that we must promote the so-called national intellect technology, when personnel understand what the patient needs and respond correctly. I would like this to be supported, too. We are implementing this technology, and recently we have seen more and more gratitude from patients for our help. The second topic, which, in my opinion, also needs to be discussed – and it was reflected in your Address – is about providing medical care to people residing in remote areas. The Krasnoyarsk Territory is, perhaps, the most vivid example of the difficulties involved in organising high-quality medical care for residents scattered across a territory of over 3,000 kilometres from north to south. Clearly, we can’t build a modern multi-specialty hospital in every small village. In this regard, it is critically important to follow certain guidelines for establishing medical institutions throughout the territories. It is important to make proper arrangements in the regions and cities to make sure patients from small villages are taken to specific hospitals in a timely manner. I am glad the ambulance aviation service was supported. This service has been in existence at the regional clinical hospital in Krasnoyarsk since 1940. Perhaps, we are among the regions that are making the most of this service to provide specialised medical care to patients in the Krasnoyarsk Territory. Last year alone we used this service to save the lives of 3,500 patients, of which 530 were children. It is important. And the patients are very appreciative. Thanks to the project introduced in Russia last year to support ambulance aviation, we were able to use domestic aircraft with proper patient stability equipment. Please keep this project going, and use more light helicopters to transport patients, which will improve our results and provide fast service. Thank you very much for your attention to our sector, in particular, to regional medicine. I wish you every success. Vladimir Putin: Thank you very much. I will comment on certain points. Concerning the quality of medical care and the issues arising from it that are related to clinical guidelines, as I understand it, the Healthcare Ministry has drafted these guidelines, and they are being approved by the federal executive bodies. (Addressing Veronika Skvortsova.) When are you planning to introduce them? Veronika Skvortsova: Mr President, everything has been approved, and the main legal department produced the final document. It was submitted to the Government and will soon be reviewed by the drafting committee. Vladimir Putin: So, it will be submitted to the Duma and become federal law. So, things are moving in a rather specific and proper manner. You are right, clinical guidelines alone will not do, although they are critically important. Perhaps, they are the key to everything, at least, there will be benchmarks which can be used during performance reviews of medical institutions and specific doctors. However, you mentioned that there are also technical personnel in addition to doctors and medical staff, and everything matters here, the actions of each person matters. What can I say? This is part of our general culture. Here, the importance of culture in the broad sense of the word is so great that it cannot be overestimated. So, in addition to education, healthcare and infrastructure, we should not forget about culture, or we will fail in any industry. Of course, we must work on this, in specific industries, and your most important industry, in particular. Now about easy access to medical care. I have really spoken about this, I believe this to be very important, and we are talking about this for the third time today. We must develop paramedic centres as well as mobile medical stations. These are accounting items, I repeat, they are counted; we will work on it persistently. Now I am not speaking about concrete numbers in children’s healthcare. We have started allocating an additional 10 billion, and we will work this way. Now I am speaking without numbers, but we will work on these areas. As for aviation, it is clear that our enormous country – you spoke about the Krasnoyarsk Territory, and it is very huge, like an entire state – so we cannot do without aviation. In general, the distribution of health facilities in the region is, first of all, up to the region; the region, governors and deputies of the legislative assemblies are responsible for it. We help and we will help, let us say, with the development of ambulance and medical aviation. The only important thing is for it to be used effectively. I have visited a region recently. There is a helicopter, which was bought long ago, and nobody uses it. Why did they spend the money? Everything can be explained: petroleum is expensive, or kerosene, or maybe the personnel is not ready. They should not have bought it then; they only wasted money on it. This is why we will do everything for development, we cannot do without it in Russia, but the things we have work quite effectively. But healthcare organisers in the regions as well as the medical community must carefully monitor these things. I think that is all. Thank you very much. Did anyone want to say something? Please. Dmitry Ivanov: Mr President, I head the Paediatric Medical University, and, in addition, I am the head neonatologist in the Healthcare Ministry. My name is Dmitry Ivanov. I would like to say that the construction of perinatal centres and, to tell the truth, the unprecedented attention from the state, the Ministry and you personally to the infant and child mortality rate yield results. We have enormous potential to decrease infant mortality even more. In addition, my colleagues have already said a lot, but I think that probably if there were target indicators to lower the mortality rate, this would also have results. I think we have great resources here. Vladimir Putin: I think we have set these goals. Veronika Skvortsova: We have, and the child mortality rate has decreased 30 percent in five years. Last year it was equal for villages and cities alike for the first time; this has never happened before. So, there is progress, but Dmitry Ivanov is right, we have a lot to achieve and we have additional resources. We will continue to lower it. Vladimir Putin: He is talking about including it as an objective, am I right? Dmitry Ivanov: Yes. Further decrease. Vladimir Putin: It is true, and this is how we will do it. I completely agree with you. This is a key area in medicine in general and children’s medicine in particular. Of course… This is why we have constructed perinatal centres and this is why we will develop all children’s medicine. This is why we allocate additional resources: 10 billion per year. We will see to it. Alexandra Budova: Good afternoon, Mr President. My name is Alexandra Budova, and I am the head physician at the Murmansk Regional Clinical Hospital. I would like to join the words of gratitude from my colleagues. I know problems in our medicine from the inside. I was born into a family of doctors and have been in this profession for almost 28 years, first as a nurse's aide. I remember very well how, in the late 90s, brilliant green antiseptic and gauze bandages were brought into hospitals, and today we are already discussing proton therapy and how quickly our modern high-tech complexes are created. But what do I want to say? Medicine and healthcare can never be isolated, or in other words, it is an area that interacts with others very closely. So today I would like to express words of gratitude for what I heard in the Presidential Address to the Federal Assembly, that the government pays very serious attention to reforming and developing the education system. I saw what they do at the Sirius centre. I see how the Agency for Strategic Initiatives has worked out a system for finding talents, how we have learnt to work with these children and human resources. This is very important because our future depends on our present. I want to express separate thanks for the reincarnation and government support of the mentorship system. You know, it was always accepted in medicine from time immemorial, yet, nonetheless, it has somehow eroded. At present, this very important thing is being revived. There is no medical university in our region, but we engage medical college students in our project activities. Our hospital has created a special project: eight topics for female college students. You know, such a fresh, non-traditional and offbeat vision of some problems that we are no longer able to solve ourselves has appeared. Next week will see the final stage of this contest and I realise: what began with a formal message to revive mentorship has grown into such a proper, vivid project. So, thank you very much. You know, Russia is a country of talents. Vladimir Putin: Thank you. In conclusion, I would like to thank you again for this meeting. I want to say that it has practical meaning and practical sense, because much of what we heard today, my colleagues from the Government and I, we will certainly summarise this, put this into corresponding documents and instructions and, while working on, preparing corresponding executive orders, including in the healthcare sector, I will certainly try to take into account everything that we discussed today. I want to say again to all of you thank you very much for the results of your work, and I want to wish you every success in your so very important, so very necessary and still more and more interesting profession. Indeed, today I toured the centre, where we are now: it has fantastic things that were impossible to even dream of yesterday, to even think that this could be possible. Today, all this is being done, being done in our country, being done so interestingly, with such enthusiasm and by people, who are so passionate about their cause. All the best to you. Thank you so much.