Dmitry Medvedev: Good afternoon, colleagues. Welcome to the meeting of the Government Commission on Socioeconomic Development of the North Caucasus Federal District. As agreed, these meetings are being held in capitals of the regions that make up the federal district. Today, we are meeting in Makhachkala, Dagestan. We will focus on healthcare and education, which are topics of paramount importance and complexity for the regions in question. The systemic upgrading of these spheres should be reflected in the draft government development programme for the district. Please bear in mind that the draft must be submitted to the Government on or before December 1.
Before we start our work, I would like to once again congratulate all Dagestan residents on the opening of the Gimra Tunnel that connects the mountainous regions of the republic. It is 4,300 km long and makes drives to mountainous regions and other villages 100 km shorter. This is the longest tunnel in Russia and possibly any CIS country. This is a major event that has been planned since Soviet times. It’s good that we have completed this project. I hope that the people of Dagestan will appreciate the newly available routes for driving around their native republic.
Now back to today’s topics. Let’s begin with healthcare. Normally, people cite the peoples of the Caucasus as an example of longevity. I hope that this association will hold true for many years to come. However, this often has to do with the favourable environment and strong genes rather than the good work of the healthcare system. We need to improve the healthcare system in the Caucasus. To do so, we need to build enough medical institutions and have enough doctors and other medical staff.
I have just visited the Dagestan State Medical Academy, which is a major 80 year-old educational institution. It’s a well-established institution with a strong faculty, but teaching arrangements need to be improved anyway. I hope that the Minister of Healthcare will share with us some ideas on how this can be accomplished in the North Caucasus Federal District.
Birth rates are high throughout the region, but infant mortality rates are almost twice as high as in the rest of Russia at 13 vs. 7.5 per 1,000 live births. Some republics just don’t have children’s hospitals whatsoever.
We need to think about it and do something about it. I know that the situation is like that in Ingushetia and Karachayevo-Circassia. This is a serious issue. Paediatricians and physicians are in short supply in the area. They need 1,500 more of each in the region. As a result, there are problems with modern diagnosis and proper treatment at the primary care level. The government programme should provide for the construction of new healthcare facilities and the upgrading of existing ones. Of course, projects under construction should be completed, although the financial situation is difficult. Nevertheless, we must see the existing projects to completion.
We also need to encourage medical graduates to return to their native regions, which is particularly important for rural areas. Heads of the regions should note that they should work along with the federal authorities and come up with proposals for the state programme regarding facilities and personnel. You should work together with the Ministry of Healthcare to meet the established deadlines. It is also important to adopt modern information technology in healthcare, as it will increase the efficiency of management and accounting in the industry and create modern comfortable working conditions for doctors. Unfortunately, some regions have not yet started to disburse funds from the Federal Mandatory Medical Insurance Fund that have been allocated for specific goals. This is wrong and has to be dealt with.
Now, with regard to education. We are aware that the quality of education determines life prospects and the professional future of young people. This is a very important consideration for this region, because unemployment rates in the North Caucasus are the highest in Russia. To a degree, this is also a matter of preserving the shared cultural and spiritual environment in Russia and countering the attempts to lure young people into extremist activities and violating our laws.
This year, the federal budget allocated nearly 10 billion roubles to the district’s regions to modernise the educational system and repair school buildings and facilities; another 360 million roubles were allocated to help young teachers buy housing.
Unfortunately, the situation in Dagestan and other republics remains difficult: there are 29 schools where classes are held in three shifts. This has to do with substandard school systems and, of course, high birth rates that are common in the North Caucasus region and are likely to remain so in the future. I have just spoken with doctors: in the most populous region, the Republic of Dagestan, there are about 3 million schoolchildren. Most likely, the number of births will double there soon. It used to be 40,000 births a year several years ago, now there are about 50,000 plus, and soon there will be 75,000 – that's almost double what it was.
Similar processes are going in other republics – perhaps not as fast, but this is a common problem. The burden on schools and preschool institutions will increase, so the state programme must include solutions to this problem. Please note that the issue is not only about the federal budget, it is also about your own funds and alternative sources that should be put to good use. The federal budget will, of course, have to bear the brunt of it.
This year, we have introduced a mandatory course on the foundations of religious cultures and secular ethics in the fourth-form curriculum. It is very important to have this course taught by competent teachers, preferably university-trained teachers, not theologians. The latter may be invited as guest speakers, of course, but it's still a secular, not a theological course, so heads of regions should take it under their personal supervision and come up with proper proposals.
Professional training is another issue at hand, since it trains employees for the needs of our economy and social sphere. I am referring to teachers, doctors and specialists in construction, power engineering, transport, agriculture, tourism and other services. This is one way to resolve the problem of unemployment as well. Training programmes at higher education institutions should be adjusted with the involvement of all stakeholders, including the Ministry of Education and Science, regional authorities, businesses and large locally operating companies. I’m aware that the ministry is currently checking the effectiveness of higher education in this federal district, and I expect the Minister to report on this subject soon.
At the previous meeting of the commission held in late June, we discussed the development of the tourism industry in the North Caucasus. Today, we are speaking about different issues, but tourism is still important. Please note that this work should be based on public-private partnership where the government should assume some of the investor’s risks. Government guarantees are a proven mechanism in countries with strong tourism industry, such as Turkey and Mexico. We can discuss how to use such mechanisms to create a tourism cluster in the North Caucasus.
On September 24, I signed a Government resolution to allocate another 2 billion roubles to complete the construction of infrastructure projects in the Caucasian Mineral Waters under the federal South of Russia programme. An additional 12 billion roubles will go to the North Caucasus this year and 6 billion in 2013. Two more federal targeted programmes, Socioeconomic Development of the Chechen Republic and Socioeconomic Development of the Republic of Ingushetia in 2010-2016, have been reviewed and will soon be released.
We will also need to approve members of four working groups of the commission which I chair. I want to remind everyone of the personal responsibility of regional and federal heads for the proper disbursement of funds and the timely execution of our plans. I would also like to remind you that I gave instructions to heads of federal agencies to regularly visit the North Caucasus, and the health, education, labour, interior, emergencies and other ministers have visited the region. However, they should go there on a regular basis, it shouldn’t be just a one-time event. The nature of this district – its social structure and the number of problems it faces – requires frequent visits. Your decisions will, to a large extent, determine the well-being of nearly 10 million people in our country. Peace in the Caucasus, as well as ethnic and religious harmony across the nation, depend on your decisions and are our top priority.
A couple more words about education and general culture. Colleagues, I’d like heads of the regions that make up the North Caucasus Federal District to understand that we need to patiently foster the ability to coexist among the people – perhaps not the way it was done in the Soviet Union, because it was mostly done formally, but still there are lessons that we can learn from the Soviet past. This applies to all regions and republics in Russia, including Dagestan, the North Caucasus in general, Siberia and Moscow. People should be aware of each other’s cultural traditions and observe age-old social rules, otherwise ethnic conflicts and problems are inevitable. Yes, cultural traditions differ, but the law is there, so you can’t shoot in the air to celebrate things in Moscow, in Makhachkala or New York, for that matter. To put it in perspective for you, if such things were to happen in New York, it could end very badly, because the police would open fire and would be justified in court for doing so. So once again, please note that we need to teach our children proper behaviour when they are still young. We should do so together and on a constant basis.
That’s enough for opening remarks.
Let’s turn now to a discussion of the two main topics. Ms Skvortsova, Minister of Healthcare, go ahead please.
Veronika Skvortsova: Thank you very much. Colleagues, please display the second slide. The North Caucasus Federal District has some of the demographic features mentioned by Mr Medvedev, notably, the highest birth rate in Russia and rather high life expectancy, 72 years, which is higher than the national average. The mortality rate for the main socially significant diseases among adults, is close to the national average. However infant mortality is significantly higher (next slide).
One of the main tasks of all current transformations in healthcare is to create an efficient three-tier system of care. We would like to highlight this. The first or basic level includes 60% of medical assistance – this is primary medical care. The second level should be responsible for bringing down mortality and providing emergency and specialised medical aid – this is inter-municipal assistance (vascular centres, trauma centres, and so on). And regional centres should provide high-quality medical assistance. Next slide, please. To start the implementation of uniform approaches to the quality of medical care across Russia from 2013, the concept of a transitional period from 2011 to 2012 has been envisaged – the programme for healthcare modernisation.
I want to highlight the fact that in the North Caucasus Federal District the rate of implementation of the modernisation programme has only accelerated in the last two months; however in general the district is considerably lagging behind other federal districts in implementing the modernisation programme. In this district, only 31.5% of medical and preventive treatment facilities underwent major repairs against the plan developed by the regions; only 29.3% of these facilities were fitted with the equipment outlined in the plan. The following trend should be noted: 92% of medical and preventive treatment facilities have formally adopted the standards in respect of socially significant diseases; yet they have received less than 50% of the relevant allocations; which means there is not enough money to fully cover the costs of implementing these standards.
Next slide please. If we look at these formal indicators, the financial equivalent of the trend that I mentioned, as of 1 September, 72% of total subsidies of the Compulsory Medical Insurance Fund and 55.7% of the regional budgets have been spent. The Kabardino-Balkarian Republic has spent 44% and 27.2% respectively.
The situation in the Republic of Dagestan, the Karachayevo-Circassian Republic, the Chechen Republic and the Stavropol Territory is developing at the highest and the most efficient rate. Next slide, please.
The efficiency of the whole healthcare system relies chiefly on primary care. In Russia, the average number of visits to a doctor per inhabitant per year is 9.4 visits. Our aim is to get this figure up to the European level: 12 visits per year. In the North Caucasus Federal District, this figure is considerably lower at 7.6 visits, which is the lowest in Russia. And in the Chechen Republic, in the Karachayevo-Circassian Republic and in the Republic of Ingushetia it is 6.
Since patients often cannot get easy access to primary care, the number of emergency calls increases as a result, which makes the whole healthcare system considerably more expensive to run. Next slide, please. This situation is partially due to the fact that the regions are not fulfilling their commitment to open new rural health centres. Of 1,276 rural health centres due to open in December 2012, to date only 77 have opened, and in some regions no rural health centres have opened at all. Next slide, please. The same is true for general medical practices.
Next slide please. The most important factor for optimising the number of hospital beds is organising daycare in-patient clinics and the introduction of in-patient clinic substitution technology – this not only makes the system more efficient and accessible, but also considerably lowers the costs of the whole system. In 2011, Russia had 15.78 daycare hospital beds per 10,000 people, the North Caucasus Federal District had 8.57 beds, the Republic of Dagestan 1.8, and the Chechen Republic 4.58. These are the lowest figures for the whole country. If we analyse the situation in primary care, on which the level of preventive medicine, the general state of health of the population, and the quality of life of the population depend, we can see that the existing network of facilities in the North Caucasus Federal District unfortunately is failing to meet the needs of the regional population and is not developing sufficiently rapidly, thereby preventing the early detection of diseases, including socially significant ones. The North Caucasus Federal District happens to be the leading district in Russia in terms of the proportion of the detection of advanced tumours and other somatic diseases.
Dmitry Medvedev: Ms Skvortsova, all our colleagues present here are already aware of the existing problems. I propose that you focus on what needs to be done. We all know that the situation in the district is serious. Otherwise I would not be personally seeing to this issue here, so please make your proposals.
Veronika Skvortsova: Please, let’s go straight to slide 14. Given the current imbalance of the three-tier healthcare system, we have carried out, jointly with the heads of the regional healthcare departments and ministers, an analysis on optimising the system based on regional and interregional opportunities. In addition to the existing healthcare facilities, work has to be completed on the construction of a tuberculosis clinic under the Southern Russia programme in the Republic of Dagestan, five district hospitals in the mountainous districts of Dagestan, some of which will take on second-tier (inter-municipal) functions; multi-purpose hospitals and a tuberculosis clinic in the Republic of Ingushetia, an infectious diseases hospital in the Republic of North Ossetia-Alania and a clinical republican hospital in the Karachayevo-Circassian Republic. Once the North Caucasus Federal District has these facilities at its disposal, the local adult population will be provided with high-quality care for acute and chronic diseases.
Next slide, please. Currently there are two federal centres – a multi-purpose hospital in Beslan and a clinical hospital under the Stavropol Medical Academy – operating in the district. In effect these centres provide not federal, but inter-municipal functions. And in our view, the Territorial Clinical Hospital in Stavropol, the Ependiyev Republican Clinical Hospital in Grozny and the Republican Clinical Hospital in Makhachkala can perform inter-municipal functions too. These hospitals can offer the full range of specialised medical care to all residents of the North Caucasus Federal District.
Next slide, please. In order to bring down infant mortality we have to significantly develop the network of obstetric care. The Stavropol Territory has the best balanced obstetric care of all the republics. Next slide, please. To reduce infant mortality, in the short-term we need to build another three perinatal centres in the Republic of Dagestan, in the Kabardino-Balkarian Republic and a second perinatal centre in the Stavropol Territory, as well as three maternity hospitals with the possibility of providing second level special nursing care in the Republic of Ingushetia. In addition, two children’s clinical hospitals in the Karachayevo-Circassian Republic and in the Republic of Ingushetia, and two in Makhachkala and Khasavyurt in the Republic of Dagestan will have to be built. To date, some of the construction projects implemented under the Southern Russia programme could be continued. As far as new projects are concerned, the planned allocations come to 2.2 billion roubles in the 2013 budget; however, all these facilities require an additional 13.2 billion roubles. The Ministry of Healthcare has conducted a study, concluding that this will only be possible under a federal targeted programme for the development of the North Caucasus Federal District.
Next slide, please. In 2011, a total of 3,770 residents of the North Caucasus Federal District required urgent medical consultations, including 656 residents who needed an air ambulance. The Ministry of Healthcare is currently elaborating an air ambulance concept for the country and the North Caucasus Federal District is an important component of this concept. We will report on this concept separately.
Next slide, please. I’d like to ask all the heads of the North Caucasus Federal District to pay special attention to the need to monitor the computerisation of healthcare. New initiatives on GLONASS support for ambulances were introduced in July; all regions implemented this task on time. GLONASS support will come into operation throughout the North Caucasus Federal District by 15 November. There is a module on electronic medical appointments in outpatient clinics, which is due to start operating in December. So far only the Karachayevo-Circassian Republic has introduced this system completely; other regions are currently behind schedule.
Next slide, please. The most important challenge in the North Caucasus Federal District is the shortage of medical personnel. The figures are below the national average; that is true both for doctors and paramedical personnel especially in the areas that are most important for regional development: the region has a shortage of pediatricians, neonatologists, and intensive care and emergency doctors.
Next slide, please. In the North Caucasus Federal District, over 9,000 students attend four state-funded universities. In 2011, 2,320 students graduated from these universities and only 25% of those completing internship training went back to work in the North Caucasus Federal District; and only 19% of those completing residency training went back to work in the North Caucasus Federal District. This year, together with the Ministry of Education and Science, we have elaborated new mechanisms of target enrolment and contract enrolment for university and postgraduate study. These mechanisms need to be adopted more intensively in the region so that up to 90% of graduates return to targeted workplaces, as is the case in other Russian regions.
Next slide. Since the uniform federal standards that have been introduced are underfunded (currently only 47.7% of the standards have sufficient funding, although formally they have been adopted by 94% of healthcare facilities), the salaries of doctors and paramedics have not reached the target level because the salary increases are fully incorporated into the increase of the federal standard and are included in the costs. Please pay attention to this.
Next slide. A few words on medicines provision for the residents of the North Caucasus Federal District. The North Caucasus Federal District is the only district that has not presented a list of residents entitled to free or subsidised medicines, subsidised either by the federal budget or by the regional budget. In summer the Federal Service for Supervision of Healthсare and Social Development conducted an inspection and uncovered an offense: the lists of the subsidised drugs included drugs that were not life-saving medications, as well as dietary supplements, which all the regions were notified of. As a result, a prescribed drug in the North Caucasus Federal District costs three or four times more than the national average for prescribed medications, despite the federal and regional subsidies. An analysis of the causes of these excessive prices revealed not only increased purchase prices but also the inclusion in the purchasing lists of non-critical medications that have no strictly registered prices, as well as a reduced proportion of Russian-made medications. Things must be put in order without delay and in the short-term we plan to meet with the healthcare ministers of the North Caucasus Federal District in order to assess the situation and discuss ways to resolve it.
Here are some final slides. Under the healthcare development programme to 2020, all regions prepare forecasts of the state of the health of its citizens; this chiefly relates to the reduction of mortality resulting from the major diseases, cardio-vascular diseases, tumours and tuberculosis. The regions in this federal district have made more modest forecasts as regards mortality rate reduction compared with the national average. The Ministry of Healthcare will advise all regions to review these figures, because Russia is making every effort to meet the targets that have been set. This applies to infant mortality too. The Republic of Dagestan, the Chechen Republic and the Stavropol Territory have huge resources for reducing maternal mortality.
Colleagues, practically all the allocations, which cover most medical care, excluding diseases caused by social conditions, are reserved in the Compulsory Medical Insurance system. I would like to draw attention to the fact that to date the North Caucasus Federal District faces a 25.7% shortage for the territorial Compulsory Medical Insurance programmes. Thus the financial coverage per capita here is considerably lower than the national average. This is especially true for the Republic of Dagestan, the Kabardino-Balkarian Republic and the Republic of North Ossetia (Alania).
Mr Medvedev and colleagues! An analysis of the situation in seven regions within the North Caucasus Federal District reveals great hidden reserves. The Ministry of Healthcare has developed a roadmap for each region to help them overcome the existing weaknesses. We would like to maintain open contact and are ready to work together on a daily basis in order to improve the situation within one or two years. Thank you.
Dmitry Medvedev: Thank you. Now I would like Mr Livanov to present his report. Please if possible make it a bit briefer. Go ahead please.
Dmitry Livanov: Mr Medvedev, ladies and gentlemen,
The materials for this meeting include detailed background information and the relevant slides. I will talk about the basic urgent measures we are proposing for addressing problems that have accumulated over the years. The most pressing problem concerns children – according to official statistics more than 1,100 children in the 7-18 age bracket are not going to school. There are many reasons for this but I see the indifference of adults as the main one. We must spare no efforts to make sure every child in the district attends school. The regions urgently need to create a personalised computerised system to account for all school-age children.
We have big problems with preschool education – a very small percentage of children are actually receiving it. Clearly it is not enough to build new kindergartens. This target shouldn’t be set at all. We need to develop alternative forms of preschool education instead: family daycare centres, private educational foundations, and so on. We are ready to provide the relevant methodological assistance to the regions.
Let us pass on to secondary schools. This academic year, a new discipline was introduced in the fourth form – the fundamentals of religious cultures and secular ethics. Of the 110,000 children who have taken it up, 38% chose the fundamentals of Islamic Culture, 26% chose the fundamentals of world religious cultures, 20% the fundamentals of secular ethics, and 15% the fundamentals of Orthodox culture. We are ensuring that the teachers involved have undergone special or postgraduate training. Representatives of religious organisations who are usually part of interdepartmental working groups are introducing this new discipline. They consult teachers but only rarely conduct the classes themselves.
Mr Medvedev, you mentioned an acute problem in your introductory address – by this I mean the state of school premises and of the entire education infrastructure. I will not give the figures now. Believe me, the statistics show the district is falling far behind Russia’s average educational performance indicators.
A modern vocational education and training network geared towards industry is of tremendous importance to the district. Three interregional departmental resource centres have been established this year. The tourism industry needs a comprehensive basic centre to draw up curricula for education and training to meet both the present and future needs of this and other related industries. Such a centre could be set up on the base of the North Caucasus Federal University. Preparations are underway. We think the district will need another three state-of-the-art centres to meet the demand for labour.
The district currently has 64 institutions of higher professional education, of which 30 are government and 34 private ones, plus 117 branches of 80 government and 37 private universities. We have finished collecting information about the work of all universities in the district, and found that more than a half of them show significant room for improvement. The Federal Service for Supervision of Education and Science (Rosobrnadzor) also checked 152 educational establishments and their branches out of a total of 181 in 2011-2012, and will check the rest by the end of the year.
Signs of failures have been revealed in a third of the total number of universities and more than two thirds of the branches, giving grounds for suspending their licenses. We intend to summon working groups next month and discuss the situation in every region of this federal district so that practical decisions can be made on how to proceed in these cases that have come to light as a result of our monitoring and the Rosobrnadzor checks. Our first consideration will of course be the interests of students. None of them will be expelled, they will all continue receiving tuition in one form or another. However, the district educational network is clearly redundant and has to be restructured as a matter of urgency.
Finally, I would like to talk about the measures we propose to implement in the years to come. The regions of this federal district have received the following educational allocations at all levels this year: out of a total of 18 billion roubles, 500 million is for preschool education, 9.5 billion for secondary schools, 400 million for secondary vocational education, and 7.5 billion for higher professional education. We believe that our main goal is for the district to reach the national average levels by 2020 in terms of basic education development indicators.
This goal will require a lot of time and significant funding. We propose that an additional 25 billion roubles a year should be earmarked in the near future for the state programme to develop the district. These extra funds will enable every region in the district to implement the roadmap on providing the necessary number of kindergarten places (within the limits I mentioned), step up the pace of construction of schools, and establish four basic training centres of secondary professional education for undergraduate and postgraduate training of a qualified workforce for major companies and priority sectors of the region’s economy.
Having three separate school shifts in Dagestan and Ingushetia definitely presents an acute problem. So as part of the measures I mentioned, each of these republics needs to build at least 10 new schools a year. We are currently working on two model projects for such schools – a village school for 700 students (with a possibility of transporting pupils by a collecting vehicle), and an urban school for 1,000 or more students. Ten such schools a year need to be built in each of these republics if they are to meet the national average standards by 2020. That concludes my report.
Dmitry Medvedev: Thank you, Mr Livanov.