Measures approved to ensure human resources development in the healthcare system
Dmitry Medvedev: As you can see, we have these buttons and screens here. This is to remind everyone that time is valuable. The speakers will see an indicator when they’ve exceeded the time limit.
Now we’ll discuss healthcare issues and the human resource potential of the healthcare system. Of course, this issue touches every family and every person because the quality of hospitals and outpatient clinics and, more specifically, our health directly depend on the quality of doctors and mid- and lower-level medical personnel.
Dmitry Medvedev: Our task is to attract dedicated professionals to healthcare and to create a truly up-to-date medical education system. This is an ambitious and difficult objective.
Today, we’ll focus on a number of measures in an effort to eliminate medical personnel shortages. We do have a shortage of some specialists. And of course, we will review measures to improve medical personnel training levels. Our task is to attract dedicated professionals to healthcare and to create a truly up-to-date medical education system. This is an ambitious and difficult objective.
Although the number of Russian doctors continues to increase, this country still does not have enough. I would like to emphasise the fact that every region is hard pressed for specific categories of medical specialists, including district internists and pediatricians. Six or seven years ago, we moved to increase the number of internists and general practitioners, and this effort has yielded positive results. Nevertheless, the problem is still there. I’m speaking about paramedics, oncologists and many other medical professions.
The situation with the nursing staff is no less complicated. As of today, there are two paramedics/nurses per doctor. This isn’t the most efficient proportion; we need to make it 3 to 1. Just to remind you, in most countries with modern healthcare systems, the proportion is 5 to 1. And many duties that doctors perform here would be better suited to nurses and paramedics. But this is simply one of the results of the medical training in our country as well.
The problem is not only that there are not enough experts in certain areas of medicine, but also that they are distributed unevenly in healthcare institutions. Small towns and villages are lacking medical personnel. Well, they lack specialists of other professions as well, but we need to pay particular attention to healthcare. Also, doctors prefer working in hospitals rather than in outpatient clinics, for obvious reasons.
D.Medvedev: In November 2012, a decision was made and formalised as a Government executive order to gradually improve the compensation plan for doctors and move over to performance-assessment contracts, with doctor salary depending on the doctor’s qualification and quality of work.
We need to address all these issues in a comprehensive manner. What do we need to do? In November 2012, a decision was made and formalised as a Government executive order to gradually improve the compensation plan for doctors and move over to performance-assessment contracts, with doctor salary depending on the doctor’s qualification and quality of work. To that end, the Ministry of Healthcare is developing 31 professional standards and the minister will report on that later.
Second, we need to improve the system of medical personnel training, including additional training programmes at simulation centres. Distance-learning education programmes should be expanded and online technologies, online lectures for doctors should be used more broadly, so as not to distract doctors from their practical work for long.
The system of admission to medical universities will be improved as well, along with skill-upgrading programmes for professors, teachers and the management personnel in medicine and the pharmaceutical industry.
Third, an information system – a federal register of medical personnel – must be created. It will list people working in healthcare and the pharmaceutical industry. The system will help oversee and predict demand for medical specialists in various regions, make plans for their training and take measures to eliminate personnel imbalances between hospitals and outpatient clinics, cities and villages.
With the help of this system, regional human resource programmes will be drawn up. The programmes will include targeted measures to support medical workers and young specialists, addressing the most needed professions first.
The Ministry of Healthcare has approved 25 of such regional programmes, including in the Belgorod Region. Governor Yevgeny Savchenko is present here, and he will tell us about his experience in this area. And, of course, we must maintain contact with the professional and expert communities. As a rule, the Government’s Expert Council is also involved in the discussion of these issues. Mr Leonid Melamed will speak about this issue today.
D.Medvedev: Improvements in the pension insurance legislation, which affects the interests of Russian citizens, are the next item of our agenda. The people of Russia should not shy away from entrusting the accumulation and management of their savings to private investment funds.
Improvements in the pension insurance legislation, which affects the interests of Russian citizens, are the next item of our agenda. The people of Russia should not shy away from entrusting the accumulation and management of their savings to private investment funds. Of course, the employees of these funds and their agents are doing their best to attract new clients. But there are problems and violations in this area, as in any financial sphere. This includes, for instance, the use of various databases containing private data for signing fictitious pension insurance contracts, and a number of other problems.
The Government has drafted a law, which stipulates administrative responsibility of non-state pension funds and their agents for these violations. Under this draft law, private savings that have been unjustifiably transferred, as well as their interest rates, must be returned to the previous insurer or insurance company. And unscrupulous funds might be forbidden to sign new mandatory pension insurance contracts because the state has to preserve pension savings to the greatest extent possible. The state must do this.
Here is another issue linked with road safety, rather than financial security. The Government, Parliament and numerous experts always focus on this issue. Quite recently, on March 29, I chaired a meeting with experts and senior Interior Ministry officials. We talked about improving the relevant legislation. This work must continue.
Today, we are examining amendments to the Administrative Offences Code. These amendments stipulate additional penal sanctions for officials found guilty of operating defective vehicles. It is common knowledge that many new and old vehicles are on the road all the time. Therefore, the technical condition of a car is one of the causes of road accidents. As a rule, their consequences are very serious.
The draft law stipulates higher administrative fines for officials responsible for operating and maintaining motor vehicles. Current fines, which total 1,000 roubles, are to be raised to 10,000 roubles. Hopefully, this will help reduce the number of road accidents, and this will also serve as an indirect incentive for renewing the vehicle fleets of public and private companies.
Today, we will also examine additions to the prospective plan of privatisation. This plan is to include 51 public liability companies and 14 state unitary enterprises, which do not directly fulfill state functions. All these various enterprises include transport companies and non-production companies. Furthermore, about 150 production facilities, including land plots and infrastructure components, will be privatised.
This should compel us to continue privatisation while maintaining due regard for the market situation. However, privatisation is a priority in its own right. Let me remind you that privatisation revenues are one of the federal budget sources.
Let us get down to our first agenda item. Please, Ms Skvortsova.
Veronika Skvortsova (Minister of Healthcare): Mr Medvedev, colleagues, having skilled medical personnel in sufficient numbers is a crucial condition enabling the healthcare system to render accessible and high-quality medical aid to the population. As Mr Medvedev said in his opening remarks, active efforts have been made since 2006 to provide the healthcare system with personnel in the framework of the Health national priority project, as well as under regional healthcare modernisation programmes and the Village Doctor programme. Promoting personnel potential has become a crucial sub-programme of the state healthcare development programme. Pursuant to the Presidential Decree dated May 7, 2012, my ministry, together with the executive authorities of the regions of the Russian Federation, has devised a series of measures to provide the healthcare system with medical personnel. This plan includes three primary sections – improving, planning and using medical personnel resources, developing a specialist training system for individuals with a medical or a pharmaceutical education, developing a material and moral incentive system to promote medical staff efficiency.
An international methodology for determining the requirements in medical personnel has emerged over the past 10 years, evolving from an empirical determination of shortages to a multi-factor calculations.
Veronika Skvortsova: As of January 1, 2013, Russia had 743,000 functioning doctors and 1,419,000 paramedics. For doctors, the ratio has increased from 42.2 to 42.7 per 10,000 people in the past 10 years, but it has declined for paramedics from 96.9 to 90.8.
Our calculations show that the country requires 45.2 doctors and 117.5 paramedics per every 10,000 people, but there are strong regional variations as well. As of January 1, 2013, Russia had 743,000 functioning doctors and 1,419,000 paramedics. For doctors, the ratio has increased from 42.2 to 42.7 per 10,000 people in the past 10 years, but it has declined for paramedics from 96.9 to 90.8. Thus, the general shortage of doctors has been reduced. At the moment, it amounts to nearly 40,000 and is maximally represented in several specialties, such as anaesthesiology, resuscitation, neonatology, addiction medicine, pathologic anatomy, paediatrics, and phthisiology. The shortage of paramedics amounts to about 270,000.
To analyse the sector’s personnel composition, the Ministry of Healthcare has developed a unified information and analytical system, the Federal Register of Health Workers, which contains data on skill levels and the age and gender composition of health workers for each region. This system makes it possible to predict changes in the personnel composition and to plan government training targets for specific specialties for each region to be handed down to state educational establishments. In fact, we are organising a continuous training system based on forecasts and real needs of each region of the Russian Federation.
The system is based on 46 higher educational institutions of the Ministry of Healthcare, which train 32,000 specialists per year. An independent analysis of enrolment quality based on the 2012 average USE performance gave the Ministry’s medical schools top ratings among national learning institutions. According to the 2012 monitoring data released by the Ministry of Education and Science, all of the Ministry’s higher schools are efficient. In addition, 24 departments at classical universities – both regional and private – train 5,000 medical specialists per year.
Importantly, universities run by different agencies, they are whether government or private, abide by uniform educational standards and accreditation criteria. Paramedics are trained by 442 secondary specialised medical schools and colleges pertaining to the jurisdiction of the regions of the Russian Federation and by 26 medical educational institutions of the Ministry of Healthcare. Their combined output is 59,000 specialists per year.
In accordance with Russian healthcare and education laws, a series of measures to improve higher medical education has been developed, including the transition to third-generation standards providing for a steady increase in the practical training level of students at university hospitals starting with their first year, reducing the variability of programmes across the entire training period, and ensuring their compliance with professional and healthcare standards across key healthcare areas, as well as reviewing and updating standard work programmes, retraining faculty, introducing high-tech simulation, virtual, and other educational tools, and using electronic information resources and decision-assistance systems. All of these processes were launched in summer 2012 and are rapidly developing.
Veronika Skvortsova: The system is based on 46 higher educational institutions of the Ministry of Healthcare, which train 32,000 specialists per year. An independent analysis of enrolment quality based on the 2012 average USE performance gave the Ministry’s medical schools top ratings among national learning institutions. According to the 2012 monitoring data released by the Ministry of Education and Science, all of the Ministry’s higher schools are efficient. In addition, 24 departments at classical universities – both regional and private – train 5,000 medical specialists per year.
Over 450 faculty members have been retrained since October, and the retraining will be completed in 2013-2014. An online medical library opened in December and basic information services were put in place. Simulation and training centres were established in seven medical schools over 2012. Seven more are scheduled to open in 2013. A transition is scheduled for 2016 where medical workers will receive proper credentials and individual permits to engage in specific medical activities. The graduates of three basic medical specialties – district therapists, district paediatricians and general dentists – will be the first to be accredited. Members of the remaining 96 medical specialties will be trained during a residency period lasting from two to five years depending on their specialty, as well as through additional career advancement training programmes.
Regular healthcare professional accreditation will be part of the continuing medical education system, which the Ministry of Healthcare is developing as part of a collaborative effort with the professional community based on a modular principle and through the use of a cumulative credit system. We plan to introduce distance learning technologies using existing databases, decision-assistance systems and a distance education server, which will make it possible to receive education on the job. To this end, we have created computerised workplaces for doctors, which will be installed across healthcare facilities as of late 2013 and throughout 2014. Such workplaces will reduce the amount of paperwork and doctors will use the time that they saved to focus on patients. In addition, nurses, who are in short supply, will be re-assigned in a more effective manner.
To achieve these goals, the Ministry of Healthcare has established an interagency coordinating council for developing continuing medical and pharmaceutical training. Also, the boards of rectors of medical and pharmaceutical universities and the directors of medical schools and colleges are now more focused on these issues. Key non-staff experts in the basic 70 medical professions and their expert boards have had their respective staffs renewed. Overall, this expert community includes more than 7,000 leading Russian professors from all over the country.
The Ministry of Healthcare has finished drafting postgraduate professional training programmes in all 96 postgraduate areas of medical studies. Training programme drafts underwent multi-level expert analysis by top Russian educational and research institutions and international experts and have been approved by the Ministry of Healthcare’s Coordinating Council on Medical and Pharmaceutical Training.
In accordance with Government Directive No 23 of January 22, new industry standards are being developed that include structural and logistical changes in the medical industry and the redistribution of healthcare professionals’ functional responsibilities. Twenty professional standards will be developed in 2013 and 11 in 2014.
The Ministry of Healthcare has established a working group to review the labour norms in healthcare. The process is to be completed by the fourth quarter of 2014.
A major element of our personnel policy is to consolidate the professional medical community, to promote corporate responsibility and ethics and to expand its sphere of operation and self-governance in cooperation with the Ministry of Healthcare and regional healthcare departments. The First Russian Conference of Doctors, which you opened, Mr Medvedev, adopted a code of medical ethics and a resolution on developing the role of the professional medical community. It was the first conference of its kind to be held in the last 30 years.
Seeking to supply outlying rural areas with medical specialists, we have worked together with the Ministry of Education and Science to introduce a new type of targeted contract-based training of students and residents based on trilateral agreements, under which a given region pledges to provide social and material assistance to students and young medical professionals. In their turn, young specialists pledge to work in their assigned position for two or three years. The pilot projects carried out in 29 regions showed the validity of this approach.
It has also been decided to extend the Rural Doctor programme, under which young specialists who accept jobs in rural regions are allocated a settlement allowance of 1 million roubles each. In 2013, the Federal Mandatory Medical Insurance Fund and regional budgets will provide the necessary allocations in equal parts. The programme will also be extended to industrial townships.
In 2014 we plan to begin the gradual conversion of medical professionals to contract-based employment, with experiments aimed at finding the best ways to implement this project depending on territorial and other medical specifications. This will enable us to assess the work of medical personnel and to calculate their pay more adequately, to improve the quality of medical services and to optimise the staffing structure in accordance with the real requirements in a given area.
These measures provide for the adoption of regional programmes to gradually deal with the shortage of medical professionals. Healthcare agencies have developed personnel recruitment programmes on the basis of the Healthcare Ministry’s action plan and coordinated regional roadmaps. All these programmes include the necessary provisions stipulated in the action plan. All 83 regional programmes were examined by April 1. By April 10, the Ministry of Healthcare recommended to the regional executive authorities to approve 36 programmes. The remaining programmes are to be adjusted by May 1 in accordance with the Healthcare Ministry’s recommendations. These regional programmes include measures of social assistance for medical professionals (see slide 10), as well as providing them with housing (see slide 11).
The Ministry of Healthcare helped to draft a programme for the gradual improvement of the system of remuneration, which has been approved by Government resolution. At present, the Ministry is monitoring the implementation of plans aimed at increasing medical salaries to the target figures and adjusting them to the average pay in a given region’s industries.
The package of measures for hiring the required number of medical personnel was discussed and approved at a meeting of the Board of the Ministry of Healthcare on November 24, 2012, meetings of the council of rectors of medical schools and institutes, the Coordinating Council on Medical and Pharmaceutical Education at the Ministry of Healthcare and the working group on healthcare at the Government’s Expert Council. Over 50 recommendations have been added to the package following public debates, and the action plan was also discussed at a meeting chaired by Deputy Prime Minister Olga Golodets on February 27. These recommendations have been coordinated with the federal executive authorities concerned, and forwarded to the Government in accordance with the procedural regulations. We request your support for the proposed package of measures, which are to be financed within the framework of the annual allocations stipulated in the federal budget for the authorities of the regions that will be taking part in the implementation of these measures. We also ask you to recommend to the regional executive authorities to implement these measures as part of their routine operation. Thank you.
Dmitry Medvedev: Thank you. Let’s begin by hearing from our colleagues in the regions and also the expert community. Mr Savchenko (Yevgeny Savchenko, Governor of the Belgorod Region), what can you tell us? Do you have any proposals on this issue?
Yevgeny Savchenko: Mr Medvedev, participants in the Government meeting. To begin with, I want to express support for the proposed package of measures aimed at ensuring the provision of personnel for the country’s healthcare system. I will speak in greater detail about some elements of this document and will share my considerations.
I think that introducing procedures that will allow for the expert appraisal of draft regional programmes this year will not only improve the quality of these vital documents, but also establish a common basis for the development of our entire healthcare system.
Now a few words about the federal registry... For the time being, the ministry is primarily using the registry to receive statistics and to analyse the industry’s human resources. It would be good if it had more functions. I think that it would be sensible to add to the registry a blacklist of medical workers – individuals who have discredited themselves. This information should be reflected in the registry and must be accessible to employers, especially if medics move from one region to another.
Streamlining medical human resources and upgrading their skills will facilitate the division of the common healthcare budget into two sections – the preventive care budget and the hospital treatment budget, while increasing the former’s share to 50%-60% of the overall healthcare expenses. Today, the relevant figure for the Belgorod Region is a little over 30%. By increasing the preventive care budget, we’ll be able to substantially reduce our spending on expensive hospital treatment. We’ll focus on detecting and treating diseases at an early stage, which will eventually reduce or streamline the healthcare budget. In parallel, we’ll continue introducing a system of effective contracts. By and large, we’ll complete the stage-by-stage transfer of medical workers to these contracts by the year’s end.
It is also important to encourage doctors to upgrade their skills. A host of factors can play a role in this respect, but I think that we should pay more attention to the formation of a competitive environment in our system. Mr Medvedev, I think that it would be wise to support the private healthcare sector and to cover the sector through mandatory medical insurance. I think that we should elaborate understandable rules of the game for everyone here. It does not matter to a patient where he or she goes for treatment or medical services He/she should go where the services are the best. If a private clinic is best, he should go there and use the same mandatory medical insurance system. This will create competition, which is a great incentive to improve one’s skills.
The need to draft standard labour norms for the healthcare industry has also become urgent. We think that their endorsement will make it possible to make medical services better and more accessible. The elaboration of professional standards should produce positive results. However, their introduction may result in enormous paperwork that will prevent doctors from having sufficient time for their patients. Maybe we should try some pilot projects to avoid this...
Finally, supporting medical workers with different social benefits is helpful in dealing with the shortage of medical personnel. In the Belgorod Region, we have an effective system for helping public sector employees to resolve their housing problems, including medical workers. We are giving a loan to everyone who is interested – 1 million roubles. This will allow them to take a plot of land, build a house and to connect to utilities. Such loans are provided with a 15-year payment period at a 5% interest rate.
And the final point. Mr Medvedev, I’ve heard this idea from Ms Skvortsova. We should support the Village Doctor project. This is a very efficient project. I’m sure that a package of measures to provide medical personnel for our healthcare system will serve as a strong foundation for upgrading the medical service quality for the public. Thank you.
Dmitry Medvedev: Thank you, Mr Savchenko. Mr Melamed, please go ahead.
Leonid Melamed (Member of the Government Expert Council): Mr Medvedev, ladies and gentlemen. The Government Healthcare Expert Council unites over 50 professionals from different fields of medical theory and practice. The Ministry of Healthcare is actively involving the council in discussing its primary initiatives and draft regulations. We hope that the expert recommendations will improve the medical industry’s performance.
In effect, this is what we can now see in the Minister’s report. On the whole, the expert community of the Open Government supports this report. And we can see, and we are grateful that many proposals, which were submitted by experts, have already been taken into account, and we hope that they will be considered during the implementation process and during the drafting of specific regulatory documents.
Experts have asked that the following aspect be noted: In the past few years, national leaders have done a lot to raise technical and equipment levels of the healthcare sector and to raise the incomes of medical personnel. It can be safely said that healthcare allocations have reached an all-time high over the past seven years relative to many previous periods. Mr Medvedev, as you have said, the quality of healthcare is becoming of primary importance. This means the extent to which healthcare allocations make it possible to achieve high-quality results for the Russian population.
Of course, the quality of healthcare is directly linked with the state of the sector’s human resources. This, in turn, depends on the qualifications of medical personnel, the selection of specialist doctors, their professional performance and their motivation. But I would like to note separately that quality must be demonstrated. As for the documents, which have been submitted, and which have to be drafted, the expert community has requested that we focus on quality, or what is now called key efficiency parameters. We must focus on evidence that medical specialists are becoming more skilled and more motivated, and that the professionalism of medical personnel has improved. For these purposes, we must focus on a relatively small number of key quality and efficiency assessment indices, which would make it possible to compare the performance of medical personnel, medical institutions and regional healthcare systems. These indices would also help compare their performance with that of foreign professionals, healthcare systems and medical institutions.
It is important that we have clear criteria and a system for monitoring ways of attaining this quality that would be open to the public. And, of course, we must largely link the motivation of medical personnel and medical institutions with attaining the above-mentioned professional quality parameters.
As for the system to improve planning and use of human resources, the expert community recommends improving the current classification of medical professions, with due account for global practices in classification and qualification requirements. We need to stipulate high-priority measures making it possible to develop the primary medical treatment service, the system of individual and group medical practice inside the healthcare system, especially in sparsely populated areas. Furthermore, we must stipulate economic incentives, which would motivate doctors to work in the regions, which are hard pressed for medical personnel. We must heed the influence of changing medical treatment technologies on human resources demand and stipulate the introduction of long-distance healthcare.
Leonid Melamed: As for the system to improve planning and use of human resources, the expert community recommends improving the current classification of medical professions, with due account for global practices in classification and qualification requirements.
As regards improvements in the personnel training system, experts focus on the need to appraise legal mechanisms for transferring specific functions to assess the professionalism of medical personnel to specialised self-regulating organisations. The role of self-regulating organisations of doctors in the system of professional improvement and certification is a highly important issue. Self-regulating organisations of doctors play a much greater role in some foreign countries, which attain a high quality of medical treatment, than they do in Russia. It would be appropriate to pay attention to this positive experience. We must stipulate measures to introduce state-of-the-art information systems and databases in the healthcare sector, to expand the network of training centres and to ensure regular compulsory training for all practicing doctors at these training centres. Much has already been said about the creation and expansion of the material incentives system. But experts have also requested that we pay attention to this issue, all the more so as the levels of doctors’ incomes and their social packages differ greatly from region to region. We need to even out their incomes and social packages. And, of course, there is room for improvement in terms of allocations for the incomes of doctors and medical institutions because we are currently lagging behind specific standards, although, as has already been said, their funding levels have hit an all-time high in the past few years.
Therefore, Open Government experts support the programme being suggested by the Ministry of Healthcare. Thank you for heeding our proposals, and we would like to note the need for additional evidence of the fact that our objectives are being accomplished, and that they are yielding the required results. Thank you.
Dmitry Medvedev: Thank you very much. Colleagues (addressing Government members), would you like to say anything about the Minister’s report? And would you also like to comment on the reports of our regional colleagues and the expert community? Mr Dvorkovich (addressing Arkady Dvorkovich), you have the floor.
Arkady Dvorkovich (Deputy Prime Minister): Thank you. I would like to make three brief points. The first deals with regional programmes. Indeed, these programmes are quite important, and we certainly focus on the provision of regional human resources. Nevertheless, while implementing these programmes and monitoring their results it is important that the integrating role of the ministry and major federal centres, which exercise the required authority, must be preserved at the federal level. I am simply asking that we pay attention to this, so that we don’t have any administrative barriers in the medical personnel training system, and so that major centres play a special role in this process.
The second issue, which is linked with the first one, is the issue of university clinics and their status with regard to our traditional system of medical institutions. In my opinion, we must focus on the need to integrate the medical education system into the university education system, and we must also develop university clinics as basic specialist-training centres.
And, third, we must utilise foreign experience in two areas. Although the relevant materials mention this, the action plan says nothing about it. First, we must send our young and not so young medical professionals to complete advanced training courses abroad. Moreover, we must invite foreign specialists here, so that they can contribute to our educational programmes at our medical centres and educational institutions. I believe that we must also devote attention to this. Thank you.
Dmitry Medvedev: Thank you, Mr Dvorkovich. Please.
Mikhail Abyzov (Minister for Relations with the Open Government): Mr Medvedev, colleagues. I agree with the proposals of Mr Savchenko, who says that it is necessary to clarify our stance on the private medical insurance system, specific rules of the game and understandable federal and regional rules in the near future because we have been discussing this issue for a long time now.
The expert and medical communities have long been discussing the future structure of the healthcare sector, equal accessibility of infrastructure for state and private medical facilities, competition between them and clients’ ability to choose the best medical facilities. If it is necessary to elaborate transparent rules and a strategy in this field, it would be expedient to discuss this issue in the Government and to prepare the relevant report this year.
The same goes for self-regulating organisations and their role and place in the certification of medical professionals. There have been lengthy discussions on this too, with various opinions in the medical community and public organisations. It appears that the Government should also make a stand on the criteria for gauging that issue this year. Thank you.
Dmitry Medvedev: Thank you. Does anyone else want to speak on this issue? Please proceed (addressing Igor Slyunyayev, Minister of Regional Development).
Igor Slyunyayev: Mr Medvedev, it is certainly a very important issue. I’d like to stress two things in this connection. The first concerns continued training of staff from primary and secondary training to university education, because people usually choose to go into the medical profession at an early stage in their lives, and this system of education has a long history, with the curricula of medical universities growing from the work of medical schools and colleges.
And secondly, many regions have opted for targeted contract training of medical professionals, although this option has not been formalised in law. I believe that as part of making plans for the labour market we should approve the system of targeted training of medical personnel based on contracts in the medium term. Thank you.
Dmitry Medvedev: It seems that the issue of targeted training has been addressed more than once at this meeting. Please proceed, Ms Golodets.
Olga Golodets: I’d like to say that the package we are discussing today includes priority measures. These are issues that need to be addressed as soon as possible, such as providing enough doctors for rural areas and also improving the quality of university education. However, there are also measures that concern the institutional development of medical education and institutional support for the healthcare system. The healthcare system includes not only doctors, but also a large number of other related professions, such physical therapists, chemists and biologists. It should be taken into account that the Ministry of Healthcare is working to implement the second stage of developing this package of measures, including together with other ministries and departments.
Mr Medvedev, I’d like to thank everyone who has asked their questions here. I also want to tell Mr Dvorkovich (Deputy Prime Minister Arkady Dvorkovich) that we plan to use the scenario which he has mentioned. In other words, we will monitor the situation using the federal register and also provide scientific methods guidance of the federal system of healthcare and its leading institutions. We did not speak about university clinics today because that issue has been included in the strategy for the development of medical science, which we discussed before and which was approved in December last year and which includes provision for developing research and education clusters at leading medical universities.
And thirdly, we are definitely making use of the foreign experience. Before reviewing tuition programmes, we carried out a full screening and chose the best three medical universities in the world – Heidelberg, Harvard and the Sorbonne.
Dmitry Medvedev: And what about Russian medical universities? We are aware of problems with our classical and other universities, which have a very low ranking. But what is the global rating of our medical universities?
Veronika Skvortsova: Three of our medical universities have been included in the top 50 or top 100 rating – I don’t remember exactly, I need to check the data.
Dmitry Medvedev: I see.
Veronika Skvortsova: In fact, there has been positive change in the past few years, and we hope now to be able to narrow the gap between the leading global medical universities and our own.
Dmitry Medvedev: Yes, we must do this. We know that the system of medical education in Russia has had its ups and downs in recent years, due to the shortage of funds and the general trend. Moreover, some new universities did not have a clinic for practical training and hence could hardly be described as proper medical universities. We need to act carefully but firmly to ensure that doctors are trained at good universities. Please take note of this.
I suggest that we approve the proposed package of measures and move on. Agreed? Let’s move on then.
After the meeting, Minister of Healthcare Veronika Skvortsova answered journalists’ questions
Question: Ms Skvortsova, two years ago Ms Golikova cited a terrible number referring to the shortage of medical personnel – about 160,000 doctors. You say 40,000 doctors. How did you manage to cope with this enormous gap so quickly, or is this difference due to the methods of counting?
Veronika Skvortsova: Of course, the methods matter. However, we did manage to increase the number of primary level medical personnel and doctors by 7,000 people over the last two years. This is a considerable achievement, but above all the figure has to do with methodology, a different approach to different regions. We are continuing to improve these methods. According to the plan that was approved today, in early 2014 we will have a multi-parameter model for calculating the number of doctors and paramedics required in each region.
To date, we have made a preliminary re-calculation depending on population density, on the proportion of the rural population in each region, on some basic demographic indicators, and we see that the requirement differs. We can roughly divide these regions into three categories. The first category has a population density of 20 people per square kilometre and includes 38 regions; the second category comprising 39 regions has a population density between 20 and 80 people; and the third category – with a population density over 80 people – includes Moscow, St Petersburg and six other regions. The demands for medical personnel are absolutely different in these categories.
Today in my report, I cited the numbers that we currently have for Russia in general: a shortage of about 40,000 doctors and about 280,000 nurses. But the situation is very different in various regions and in different medical professions, even depending on the level within the healthcare system – that is, it prevails at the primary level, of course. It concerns not only district internists, pediatricians and, to a lesser degree general practitioners, but also specialists working at the primary level. The shortage is considerably lower in hospitals, however it also exists in some professions, in particular phthisiologists, narcologists, neonatologists and some other professions.
Veronika Skvortsova: Diagnosing diseases is not an end. All patients should be entered into our record systems. We have developed customised treatment and wellness programmes for everyone.
Question: Recently, State Duma Deputy Valery Seleznyov introduced a draft law on a complete ban of fee-based medical education. What is your opinion on this issue? The motive behind this draft law is that higher education institutions take enormous efforts to help paying students, and so the quality of education falls.
Veronika Skvortsova: In 2016, we will introduce certification for all medical personnel. This means that six-year and five-year students of some departments will receive their first certification – these are graduates from medical institutes and universities. The criteria for this certification will be unified both for medical institutes of the Ministry of Healthcare and for classical universities – both for regional universities and private institutes. This certification will be carried out not by the teachers who have taught the students, but by a professional medical community. This will be a special commission on certification in all basic areas. Institutes can be under various forms of ownership, they can be controlled by different departments, but the criteria and standard programmes taught there should be unified.
Today in my report, I spoke about the features of medical education including the large proportion of mandatory practical training that is part of the last two academic years. I am referring to reducing the variety of education programmes in the last years, and linking the sum of knowledge and educational programmes to professional standards and healthcare standards in those basic areas in which we train young doctors, young specialists.
Question: Ms Skvortsova, annual medical checkups are planned to be reintroduced in the Russian healthcare system in the near future. It's known that a third of the population is scheduled to have these checkups the very first year they become available. It seems like a heavy burden (at least, on the face of it) for doctors, particularly the ones in the primary care system, which is anyway weak. How can this be accomplished?
Another question. You said there’s a shortage of 40,000 doctors: how much is that percentage-wise?
Veronika Skvortsova: We have 740,000 doctors working in the system and we need 40,000 more; 780,000 doctors will pretty much cover our needs, if job balancing is done in line with the needs of the healthcare system. Since we are talking about real people, not chess pieces, we won’t be able to avoid certain negative processes where experts go to areas that are of more interest to them. Our job is to provide personnel to rural and remote areas, and so on. So, we should have some leeway in this regard.
As for your original question, regarding annual checkups, we have carried out a substantial amount of work with each of 83 Russian regions. Indeed, re-introducing annual checkups and changing the way they are organised (enlisting large numbers of professionals and instrumental and laboratory methods), is a major burden for regional healthcare systems. However it’s a prerequisite in order to have an advanced healthcare system. In this regard, we have added annual checkups to the state guarantee programme and have laid out the standards for routine checkups in primary care. They are paid for through the compulsory health insurance system. Each region has provided us with its regional annual physical checkup programme focusing on remote and rural areas.
In such regions that are prone to certain risks, local authorities form mobile preventive screening teams. Generally, they are based in the regional, territorial or republican multi-purpose hospitals or large municipal hospitals. So far, we have bought 187 mobile systems, and plan to acquire several thousand of them in total. They are staffed with properly trained multidisciplinary teams and equipped with labs and medical instruments.
We have conducted a pilot project to introduce medical checkups in the Moscow Region and have carefully analysed this experience. This is a fairly complex region due to its ring-shaped location around Moscow. The Moscow Region is affected in particular by the outflow of personnel heading to Moscow, along with some other problems that are associated with a large rural population. Therefore, it was an enriching experience for the entire country.
We have held several video conferences with the regions based on this analysis. The all-Russian conference on annual checkups, rural health care and advanced health-saving technologies in rural areas will be held on May 31 in the Belgorod Region. This is an important topic. We believe we can get this programme on its way.
Just a reminder: we will have children annual checkups. Children will see different specialists depending on their age. Adults will have these checkups once every three years, and they will also be based on age groups: below 40, 40-70, and over 70. Of course, we will strive to diagnose diseases in the early stages. In such cases, patients will be treated and have routine screenings at specific medical institutions. Diagnosing diseases is not an end. All patients should be entered into our record systems. We have developed customised treatment and wellness programmes for everyone.
Veronika Skvortsova: As for doctors, the figure is well known. They should receive 200% of the average regional salary by 2018.
The ministry performs onsite inspections of such work in the regions together with the Federal Service for the Supervision of Healthсare and Social Development and the Mandatory Medical Insurance Fund. Just like you, we don’t want regular medical checkups to become a formality.
We analysed the experiences of the 1980s, and I specifically discussed this issue with then-Minister of Healthcare Yevgeny Chazov. The Soviet medical system was notorious for the liberal use of doctored numbers in statistics concerning medical checkups and services. We are doing our best to avoid this now in the new Russia. We realise that a lot depends on the regions, which will have to do all of the organisational work. We, in turn, perform cross-checks, do onsite inspections, and encourage public oversight over this work. We have opened a special hotline to callers... In other words, we are doing everything to obtain information about existing distortions, if there are any, and to take quick action to remove them.
Question: You mentioned that the industry is short of 270,000 nurses, and the shortage is on the rise. How does the ministry plan to attract professionals to the industry? What benefit packages do you have for them?
The second question concerns salaries. What salaries will doctors and nurses receive by late 2013?
Veronika Skvortsova: I gave the numbers today regarding the nursing staff. We have an unmatched, wide network of 244 medical schools and colleges in the regions. We also have 26 higher medical educational institutions with special departments for training nurses. We also have a dedicated research and methodical centre at the Ministry of Healthcare and three federal colleges that also engage in research, methodology and capacity-building activities.
Every year, we train 59,000 nurses. The problem is not that this isn’t sufficient. The problem is that by far not all of them go to work in the healthcare industry. On top of this, about 90,000 nurses leave the industry yearly, and of them only about 15,000 retire due to their old age, while others simply leave for better jobs.
Actually, I brought up these figures to let you know that we do not need to expand our educational network. In order to improve the attractiveness of education, together with the board of directors of higher medical institutions and colleges, we have held the Russian Congress of Nurses and updated all of the programmes in all of the key areas. Nurses also have a large number of specialties, and they are highly skilled workers, too, with a specialised secondary education, and they come in three skill categories. Paramedics are part of the fifth category near doctors. Doctors are the sixth category. We should bring nurses’ salaries up to standard with the average wage in the region by 2018. However, their salaries will vary depending on their skill level. Thus, paramedics should receive about 120% of the average regional salary as a minimum, while some nurses with lower skill sets may have salaries that are somewhat lower than 100%. As for doctors, the figure is well known. They should receive 200% of the average regional salary by 2018. These figures are included in a presidential executive order dated May 7.
In late 2012, doctor salaries were estimated at 123% of the national average. Nurses, as far as I can remember, had about 78% depending on the region.
I would like to call your attention to the fact that statistics show salary rates whereas executive orders use the average wage concept, which is not the same thing.
Veronika Skvortsova: Polypragmasy, that is, prescribing handfuls of mutually exclusive drugs is a scourge of our healthcare system, so we have developed a system to prevent this from happening by warning doctors that certain drugs are incompatible and providing recommendations on changing the dosage and so on.
As we see it, the flawed system of work rate setting for medical professionals is a problem, and revising and making changes to the work rates of doctors and medical personnel is a major part of the measures we have been discussing today. If the average pay differs so much from one job rate, while the work hours are about the same, obviously, something is wrong here.
We have set up an interagency working group together with the Ministry of Labour and Social Development, the trade unions and our medical professional community to revise the rates for various doctors and nurses proceeding from the time the doctor spends on one patient if he or she is not acting as a mere operator (you know what I mean). Naturally, a psychiatrist, a neurologist or a cardiologist need different times for examining their patients. These things are well established in international practice. We will proceed from the rates used in the majority of countries. Based on these rates we will recalculate the number of patients an outpatient doctor can and must see if they are working a single time rate and then their pay will be justified and their professional activity will be dignified.
The same is true of nurses. There is one important thing to bear in mind. Nowhere else in the world do nurses just sit copying papers while doctors see patients, because nurses, as we have mentioned, are highly qualified workers. They should work as operational, rehabilitation, visiting nurses and so on. Especially since the current policy is to develop rehabilitation in the regions and to develop palliative services which are mainly administered by nurses. Therefore we pin great hopes on modern information technology in healthcare.
We have developed the doctor’s workplace and presented it to the Communications Ministry at our joint meeting yesterday. I am referring to the workplace of any outpatient doctor, be it a general practitioner or a specialist in the primary sector. The workplace is in fact designed to provide access to various systems. It comprises first of all an information block, access to an electronic medical library we completed in late 2012, to the main information sites, reference materials and guides. It provides access to clinical protocols and standards. We have developed a decision-assistance system, which is going through pilot tests, to help doctors, especially at the primary level, to decide which drugs to prescribe because there are considerable irregularities in this matter in our healthcare system.
Polypragmasy, that is, prescribing handfuls of mutually exclusive drugs is a scourge of our healthcare system, so we have developed a system to prevent this from happening by warning doctors that certain drugs are incompatible and providing recommendations on changing the dosage and so on. The system will contain a block of all the standard documents a doctor needs, including prescription forms and referrals in which only the name will need to be written and all the other information is entered at the click of a mouse without the services of mid-level medical personnel. This is important because firstly, it cuts down on paperwork and it saves doctors time which they can use to work with patients, and also, given the shortage of mid-level medical personnel in our country, it will enable more efficient use to be made of mid-level medical personnel, who are vital for the sector.
Another theme connected with the electronic workplace is the ease of fixing up appointments to see a specialist. This is an important point because if a therapist examines a patient and sees that they need an otolaryngologist, they can enter that system at once. We locate all the otolaryngologists within a certain radius of a particular institution, see their opening hours and the waiting list, and patients who find that in the outpatient clinic where they have come there is a long waiting list can say, I want to see a specific doctor. These information resources related to management and organisation greatly facilitate access to medical assistance.
We very much hope that with the help of these modern technologies we will be able to get rid of queues and the humiliating procedures of registration for an appointment and so on. That should be very helpful. But of course in parallel we need to provide enough primary level personnel and we are making every effort to do that. And the fact that from 2016 we are introducing accreditation enabling medical university graduates who have received good practical training in the final two years to start work as primary care physicians should help us achieve this goal. We hope the situation will improve in the near future.
Question: You said in your report that a register will be introduced. I would like to know what it will contain: simply a list of doctors or some data about them? I am told that in America they have a public database where people can look up how many operations of a certain type a surgeon has performed. Will we have something similar?
And my other question is about doctors’ liability insurance. When will that system start working and how will it operate?
Veronika Skvortsova: Regarding your first question. The information-analytical base has been developed, and it contains several segments. On the one hand, it’s information on all medical workers – physicians and nurses – who work not only in state and municipal institutions, but also in private healthcare institutions. Information on their level of competence, qualifications, the training courses they have taken, repeat accreditation, medical rating (we still have it) and some other things, including demographic indicators: age (because we will have to plan the retirement of some of our staff), gender and so on, i.e. the information needed for planning and forecasting. This database also includes all the medical schools and colleges, and all the medical higher education institutions and medical faculties. The database contains information on the reserve that will join the system after a certain period of time.
Actually, we developed this database in 2011. I was involved in it myself from the beginning of 2010, forming that base and determining what information should be protected from external users (only people who do analytical and information work should have access because for them the personal data of individual specialists do not matter). Some segments should be open to the public because they effectively form a competitive environment for improving the quality of healthcare and offer choices.
Veronika Skvortsova: For the first time in the second half of 2012 the Ministry together with the professional community came up with documents, mainly financial documents, setting standards for medical care. We have developed 797 standards of which, as of yesterday I think, 781 have been registered by the Justice Ministry. These documents are thus becoming binding, no longer recommendatory. These standards are necessary to determine the overall cost of medical care.
What is the problem? Why, having basically filled that system, can we not use it in full? Because when the subjective human factor comes into play and these data are entered for each person from outside... We have found a lot of distortions and we identified these information distortions during the course of the checks that we conducted in several regions. We need to apply that system to all the clinical institutions, and ideally the system will work when information is read straight from the human resource department at every institution without any intermediate records. In fact the register will contain a staff chart plus any necessary additional information.
We plan to complete this work by the end of 2013. During the whole of 2013 there will be intensive computerization work and we hope that a large chunk of this register will be accessible directly, which will greatly facilitate the situation and make the information reliable, which is the key factor.
Considering that we are simultaneously developing open information zones that will be on the sites of every district, healthcare department or municipal healthcare organisations, where they exist, with indicators that make it possible to assess the performance of every institution, there will be information on the medical personnel. But the volume of that information is currently being discussed by the professional medical community so as not to infringe on the rights of the medical personnel, of course. So much for your first question.
The second question is about insurance. The ministry has developed a draft law on malpractice insurance. This subject was raised at a meeting in Rostov-on-Don between representatives of the Popular Front and Vladimir Putin. The draft law is ready and we are planning to initiate an open discussion with non-governmental organisations, with patients’ organisations and with the professional medical community. We think this is the right approach because medical errors are very difficult to define. They are sometimes systemic because the organisation delivering emergency care does not have the equipment to provide the appropriate assistance lege artis, that is, properly. There could be many reasons, for example, unavailability of the proper specialist at the right moment, when for example a general practitioner has to treat a heart condition. The rules specify in which cases a therapist should refer a patient, say, to a cardiologist (a therapist can treat some heart conditions, but more specific treatment that calls for a very high qualification, should be provided by a cardiologist), but sometimes the cardiologist is out of reach and the therapist has to do what he can because doing nothing is an even greater failing. But assistance like this may fall short of professional standards.
Why am I giving you these examples? Malpractice is not always committed knowingly, and a lot of errors are systemic. The range of definitions that define malpractice is currently being developed in various parts of the world, including the German Medical Chamber and especially the American Doctors Association which leads in terms of the number of malpractice suites against doctors. They have left everyone far behind: America leads the world in terms of the number of complaints against doctors. There are special organisations you could call a patients’ organisation only by a stretch, which make a profession of it and make money that way. We should keep that in mind because we have the advantage of developing this system later and we can avoid the mistakes of other systems. When I meet with my American colleagues and with US Health Secretary Kathleen Sibelius (we are constantly in touch, exchanging information and we are benefiting greatly from this cooperation) her big headache is how to keep all this from snowballing because that genie had been let out of the bottle before her time. It is a controversial subject… At this point the subject under the law is not the doctor but the hospital or the medical organisation because we are talking about a combination of the available equipment, the way medical care is organised and the competence of specialists.
We would like to insure the patient against medical malpractice and to have the medical organisation insure patients. This is our approach.
Veronika Skvortsova: Starting on April 15 we will be receiving monthly information from each region on the average salaries of doctors and paramedical personnel at every medical institution, not municipality. I want to draw your particular attention to this point because the municipalities can mix the two things together and arrive at an index which looks right in every respect. But when it concerns specific medical organisations we can see what salaries are being drawn by doctors and nurses.
Question: With your permission, could we go back to the question of salaries. Some regions are already reporting that they are paying decent salaries to doctors and middle-level personnel: 37,000 roubles, 24,000 roubles, respectively. But if you have ever visited internet medical forums, the doctors there cite much lower figures. My question is, do you have feedback from the grassroots, from the people on the ground? Because the regional administrations of course are interested in making things look good.
Question: And a follow-up question…
Veronika Skvortsova: Yes, of course.
Question: Everybody understands that the reason there is a shortage of doctors is the appallingly low salaries. I know, for example, that in the Tver Region a doctor’s salary is 8,000 roubles. From what you said, it will increase to 200% over two years, which means that it will be 16,000 roubles, or even less if today it is 123% of the average regional wage. Doctors won’t settle for such a salary and the regions will still be without specialists. My question is, why is a doctor’s salary made up of numerous components? If the personnel shortage is so serious why doesn’t the state ensure a normal transparent salary for doctors so that the sector can work properly?
Veronika Skvortsova: You are right of course that in some Russian regions, not everywhere, but in some regions (it is a common situation in the Central Federal District, in some Siberian regions and some signs are coming from the Urals Federal District) doctors and nurses have very low salaries at some medical institutions. I would like to explain the methodological situation today. For the first time in the second half of 2012 the Ministry together with the professional community came up with documents, mainly financial documents, setting standards for medical care. We have developed 797 standards of which, as of yesterday I think, 781 have been registered by the Justice Ministry. These documents are thus becoming binding, no longer recommendatory. These standards are necessary to determine the overall cost of medical care. Every standard for treating a given disease is essentially a price list of all the medical services that may be potentially used to treat a certain typical case of the disease as well as the drugs and medical implants, plus blood preparations, diet management, etc. The standard spells out all the main blocks and indicates how many times on average an element can be used in a standard. It is basically a check that helps to determine the average cost of treating a patient with a specific disease. Knowing the average cost and knowing the statistics of incidence of the disease we can assess the total amount of money required for all the country’s citizens to treat a certain disease and then calculate the cost of medical assistance assuming that the diseases selected for the standard account for 90% of morbidity, that is, all the main classes of diseases, plus separate standards for orphan diseases that are very costly to treat. They are rare, but their cost is high and that is also taken into account. For the first time since the demise of the Soviet Gosplan (State Planning Committee) we did this in 2012. For the first time we made a case for the amount of money that must be in the system to finance the standards which our professionals, our medical community have written up.
The money is then distributed among the regions, each of the 83 regions proceeding from the budget situation in every region, the morbidity and mortality rates, and certain regional indices and coefficients. This is a special methodology handed down to us by the Ministry of Economic Development and the Ministry of Finance. The money is distributed among the regions, and is then distributed among the clinical and preventative institutions, medical organisations.
For this money to be distributed in a more targeted way, depending on the type of the institution, plans and urgency, the Ministry together with the World Bank did some research in 2012 and, drawing on the best international experience, developed a special method of directing resources to a specific medical institution based on what is called the Diagnosis Related Group (or DRG) concept, connected with a diagnosis made in a group of diseases).
Each group uses specified rates because there are groups where the cost of medical assistance is determined by the cost of, say, an artificial joint or an expensive implant, and accordingly, the cost of the medical labour makes up only 20-30% of the rate. In another disease group, for example connected with abdominal surgery, salaries make up about 80% of the rates, because the main thing there is the ability of a given surgeon.
The DRG system was invented 40 years ago in Australia and is now the main method for determining rates and targetedly allocating money to institutions used around the world: it has been perfected in Australia, they have been refining it for 40 years now; in Germany it was first adopted 25 years ago. It was also introduced in America and everywhere else. We have also adopted this method, and in November it was approved on our order and, accordingly, circulated to the regions as a recommendation in December.
How are things organised in the regions? Each region has its own rate commission which includes representatives of every region’s healthcare department, of the medical professional community, of the regional administration, the trade unions, patients’ organisations, and so on. Law No. 323 On the Basics of Health Protection for Citizens (the system law) and No. 326 On Mandatory Health Insurance prescribe how these rate commissions should operate. To begin with, all the money allocated to a region goes to this tariff commission. Next the commission (it enjoys some independence) determines the mechanism whereby this money is to be distributed to institutions. There are three basic mechanisms. One is the most outdated, which no one uses anymore, although some regions still use it; this is when the allocation is based on the number of bed-days or the number of out-patients. These methods are from the 1950s and 1960s; they don’t show how efficient the system is but are merely added to the formal indices of treatment given to in- and out-patients. Then there are methods that we describe as modern. Everyday I talk with the regions, separately and collectively, in video conferences and otherwise – addressing governors and deputy governors, as well as ministers – to explain how the tariff commission is to operate. The point here is that this authority belongs to the regions themselves. Methodwise, the federal centre can help them, and we issue recommendations, suggesting some approaches to rule-setting and so on, but they do everything themselves.
Veronika Skvortsova: We are planning to work with the Mandatory Health Insurance Fund. The Fund, too, has a right through its field branches to monitor finances. Likewise we will cooperate with the Federal Service for Supervision of Healthcare and Social Development to exercise what is known as government control and monitor each organisation.
Our concern is to not step on the authority of the regions and be accused of misbehaving, because every region prizes its autonomy and what the law empowers it to do.We just want to lineup a kind of monitoring. And we have provided one: starting on April 15 we will be receiving monthly information from each region on the average salaries of doctors and paramedical personnel at every medical institution, not municipality. I want to draw your particular attention to this point because the municipalities can mix the two things together and arrive at an index which looks right in every respect. But when it concerns specific medical organisations we can see what salaries are being drawn by doctors and nurses. This monitoring system is now in place. On the fifteenth of every month we will receive data about the previous month. What’s more, the Ministry’s spokesman Mr Salagai, who is here, has set up a hot line to receive information in the form of open letters to me or complaints about irregular practices in some region or other, not across the board, yet at a specific institution.
I wish to remind you that each institution has been following these special rules for payroll since 2010. In each department or unit, the department head has a lot of authority – he decides, for example, how many people he should employ in a particular unit, what salaries to pay employees; in fact he distributes the wage bill inside every institution. This independence, when first introduced, was designed to enable the medical staff to work with maximum effect and savings within concretely specified conditions in every institution. But, of course, if a dishonest person heads an institution, he has the opportunity to abuse his power to detrimental effect.
So we all should … First, we would appreciate it if you, too, would inform us of any negative developments in specific areas. This is not an all-pervading situation everywhere. In many regions and at many institutions, things are really improving. But the fact that such disgraceful practices occur calls for a rapid response, especially since, in some cases, those who work are still treated badly despite a shortage of personnel.
We are planning to work with the Mandatory Health Insurance Fund. The Fund, too, has a right through its field branches to monitor finances. Likewise we will cooperate with the Federal Service for Supervision of Healthcare and Social Development to exercise what is known as government control and monitor each organisation. We hope that we will be able to prevent many abuses in this way. But human nature is human nature. Human presence always presupposes some risk, so please work with us. We will only be grateful to you.