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President of Russia Vladimir Putin: Good afternoon. Let us talk about the development of the healthcare system.

Healthcare Minister Veronika Skvortsova: Mr President, you outlined serious tasks and goals for the healthcare system in the May Executive Order and in your Address to the Federal Assembly. Taken together, they are designed to increase life expectancy in the country and reduce the mortality rate across all age groups.

After discussing the matter with demographics experts, we have chosen the most optimistic scenario – the possibility of reducing the mortality rate – and have coordinated targets that are even better than the most optimistic projections.

We analysed various possibilities for reducing the mortality rate. According to Rosstat [the Statistics Service], we can reduce the rate by 160,000 deaths by 2024. We have set a higher target – cutting the death rate by 228,000. We can achieve this by working in three areas: combatting cardiovascular diseases (the number one cause of death) and oncological diseases (the second leading cause of death) and reducing death rates for children of all ages. The ultimate goal is to protect the life of our people. These are the three main components of the National Project Healthcare.

It should be said that 50 percent of the success in the achievement of these targets depends on the improvement of first aid and on preventive measures. This is the fourth component. In addition, we must implement crosscutting programmes to attain the main results and ensure the required quality of medical services, which is the responsibility of the nationwide specialist medical research centres that have been created on your instructions. These “captains of the medical industry” supervise and control specialist branches in all the 85 regions, with skilled personnel and individual programmes and digital technology.

In fact, the results of our analysis provided the basis for the national project, which is divided into eight federal projects. There are four basic projects and three auxiliary crosscutting projects. The eighth project, which you have instructed us to implement, concerns the development of medical services exports.

Over the past two years, we have increased inbound medical tourism from 20,000 to over 110,000 people. Last year, it earned us $250 million, which was invested in the further development of our healthcare facilities. We have formulated ambitious goals for the following period, and I believe that we will accomplish the task of increasing the export of medical services fourfold, or maybe even more.

There are five underlying principles for the implementation of these federal projects. The most important of them is disease prevention. We must promote and encourage healthy living and simultaneously create conditions for this. This is the target of the Demography National Project, which our best psychologists and sociologists are implementing with reliance on the legal framework and infrastructure.

You have asked us to introduce annual health examinations throughout the country within six years. Last year, 48.5 million people underwent such examinations. The figure is 58.4 million when those who underwent occupational medical examinations are taken into consideration. We plan to increase the figure to over 80 million by 2021, and 90 percent of population, or over 130 million people, by 2024.

It should be said that occupational medical examinations are being improved, and we have updated the regulations. This year we have launched three modern cancer-screening systems for the most commonly diagnosed cancer types. In future, we plan to further raise the standards of occupational medical examinations.

The second point is the quality of health care. This is a rather complicated part of all our projects, because Russia has never had unified national quality standards. Over the past five years, our expert community has for the first time worked out consensus documents, clinical recommendations, and quality criteria. They are now being widely introduced throughout the country. The task of the national health centres is to implement them in their divisions in all regions of our country.

The next point is who will have to implement them. The Executive Order stipulates very tight staffing requirements – we plan to reach a 92 percent level of staffing at primary care institutions with medical workers and 88 percent – with doctors by 2021. We actually expect to ensure full staffing in 2024. We have all the estimates and calculations. We are also staffing cardiovascular and oncology services.

This year, more than 100,000 doctors are doing a remote professional training course through the federal portal for continuous medical education. With the paramedics, we will have two million medical workers trained by 2024. And from year to year we are introducing accreditation and licensing of professional medical activity, which allows us to license only those who meet the criteria.

Another important field is the availability of health care – a large part of the Executive Order is devoted to this. By the end of 2021, we will fully ensure the availability of primary healthcare, including in rural areas. This year, we will build 315 medical and obstetrical stations and rural outpatient centres. We will purchase 206 mobile medical units for villages with populations under 100 people. We have a clear plan – we know what we will do each year, and by 2021, the problem will cease to exist.

We will not only build more medical and obstetrical stations where there are few. Please note that we are using the geoinformation system we built in late 2015. It is regularly updated and shows the risks of a particular type of medical care not provided on time in each locality (157,000 across the country). We will upgrade about 1,200 medical and obstetrical stations that are in a really alarming condition at present.

By 2021, we will also establish central dispatching offices in all regions (in fact, half of the regions already have them), which will connect the ground and air ambulance services. It is very important to abandon the centralised regional administrative structure and simply dispatch any crew that is closest to the patient.

We are actively developing telemedicine. Our 22 national centres and all the 85 regions will be connected by a vertically integrated telemedicine network by the end of this year. We hope that as of the start of 2019, we will begin a step-by-step rollout of new doctor-patient telemedicine principles.

Mr President, one of the things I could not fail to mention is of course the importance of ensuring that medical services are patient-friendly and respectful. I remember, less than one year ago, we visited one of the first so-called caring outpatient clinics, a comfortable clinic in Kirov Region. You asked back then whether other clinics of this kind would be created. There are now 1,147 such clinics in 40 regions, and within three years we expect 3,800 outpatient clinics and child outpatient departments to be covered by this scheme, after which more than half of the adult clinics will move to this framework by the end of 2024.

It actually works, and the system has not become less efficient as more and more clinics joined in. Waiting time dropped two to five times, and queues are becoming a thing of the past. In addition to this, there is another important element in this block, which is the development of the insurance representatives as an institution. There are now 9,000 insurance representatives who are becoming more and more effective.

Vladimir Putin: Are they present at medical institutions?

Veronika Skvortsova: Yes, they are. Last year, they invited 22 million adults to preventive screenings via SMS, and 60 percent responded within three weeks. We see that once people feel compassion and empathy, they respond.

We are now working on special programmes for insurance representatives so that they inform people about their health groups, and help find the right doctors for preventive check-ups. This means that insurance representatives are becoming part of the team.

We have included an indicator in the national project whereby every health insurance company will have to create a patients’ rights centre in order to have fewer lawsuits, and introduce the latest mediation methods so that conflicts are resolved out of court.

And, of course, innovations. We are actively developing our innovation-oriented cluster. The year of 2016 was associated with vaccinology and we developed several original domestic forms of medication, some of which are used for the treatment of highly dangerous infectious diseases. Last year we worked on automated devices that identify biopathogens.

This year we are carrying out 25 projects with the emphasis on oncology. By the end of next year, we will acquire a number of unique test systems. We will use methods of liquid biopsy that will signal the emergence of cancer long before its clinical manifestation. These are personalised methods of treatment.

Vladimir Putin: So this amounts to cooperation with the pharmaceuticals and medical industry.

Veronica Skvortsova: It is very active.

Vladimir Putin: Do you remember that it was mentioned many times that the defence industry was particularly upset by the absence of orders.

Veronica Skvortsova: We will have truly unique medicine. We are already launching certain technologies. These are technologies whereby T lymphocytes are taken from a patient, modified and reintroduced. Having been subjected to shock and immune failure, the patient becomes healthy again.

I am referring to a personified oncovaccine. This will be very interesting and there are no analogues to this vaccine in the world for the time being. There are also oncolytic viruses.

We have a young, intellectual and optimistic team of people from practically all regions.

Vladimir Putin: This area is also being developed abroad.

Veronica Skvortsova: We know what they are developing and are actually relying on their experience but we want to go further. We want to proceed not just from a cancer biopsy but from an opportunity to identify fiducial markers that may provoke the development of a tumor in a patient by using bio information and mathematical technology. We can then make a cocktail from various protein preparations that will cause regression of the tumor and it will simply disappear.

We have experience of work based on a simplistic approach. One of our patients received such treatment this and last year, and we can now see the result. This was a case of glioblastoma, coma and cerebral oedema. This medication took care of the swelling, then the tumour shrank and the patient was able to go back to work. Almost a year has passed since then.

We have used this vaccine three times already. The PET study shows that the points of growth remain intact, so we cannot just go ahead and cure it. We just need to go deeper and find ways of simultaneously treating different loci of this tumour. I think this is the right way to go and there will be results.

May I say a couple of words about oncology?

Vladimir Putin: Of course.

Veronika Skvortsova: Mr President, we have achieved certain positive results since 2012, the five-year survival rate is up and one-year mortality is down. However, if we look at standardised cancer-related mortality rates, we are very close to Europe. This is a standardised indicator based on the population structure. However, we are still lagging behind in terms of detectability. European doctors detect many more cases at early stages. The mortality rate in Europe is lower as well – we have it at 22.5 percent, while theirs is at 17 percent.

We have set ourselves a goal to achieve European indicators by 2024 and go just a little above their current levels. We have developed a programme with the participation of over 60 of our leading professors, oncologists, radiologists, radiophysicists, radiochemists, and so on. If we manage to implement it, we will bring Russian healthcare to a new level.

The programme is about forming total alertness through screenings for cancer in primary care. In the event an alarm goes off, we will form inter-district outpatient oncological centres (they are easy to create and do not require any construction efforts as all we need to do is make a few arrangements), which will allow us to make a diagnosis in a matter of two weeks. In case we have doubts, we will form 18 reference centres that operate, including in digital format, based on morphology, immunohistochemistry and MRI-CT.

The goal of the first phase is to form a correct diagnosis based on international code. Unfortunately, only half of the diagnostic code gets filled out in most of our regions today and includes only localisation and close and distant metastases. There are many errors in morphology, immunohistochemistry, and the genetic analyses do not look good at all.

For example, there may be a breast tumour with the same localisation, but there may be five genotypes meaning there will be five different treatment protocols using different medications. We are, in fact, ready for this programme. We have created 77 clinical recommendations containing 940 patient models.

This is the first phase. The next phase is treated quite differently, for example, stomach cancer. We did not just record everything. We crunched the numbers for each bloc; we did everything from the point of view of international codes and clearly distributed the drugs within each group.

We have thus set a goal for the entire country. In conjunction with the best federal forces, we will create a single system based on an oncological information programme. In fact, a tentative diagnosis at an outpatient unit automatically opens the oncological programme interface. From then on, we follow every patient through all stages and monitor the accuracy and timeliness of the therapy.

Our goal is to make sure patients are immediately sent to a facility where they can receive medical aid under the clinical protocol. This knowledge has been updated by creating a minimally sufficient level of passports for the regional, district and federal levels.

We hope to make proton therapy – top-level nuclear medicine – part of the state guarantee programme beginning in 2021. In December, we will open a nuclear medicine centre in Dimitrovgrad with four proton accelerators, of which two are unmatched in the world. For example, a proton accelerator for treating children will be the second in Europe. In addition, there is an accelerator designed for very small tumors under 1.5 millimetres in diameter, like an eye melanoma, for example.

We strongly hope that we will be able to implement this without distortion across the regions eventually. This, in fact, determines the outcome. If we adopt a single high-quality approach, our medicine will reach a new level. We will do our best to get there.

Vladimir Putin: Fine. Some countries with developed healthcare systems have a mortality rate under 17 percent.

Veronika Skvortsova: There are some boasting 12 percent, but if you take the EU countries as a whole, the number is 16 something, close to 17 percent.

Vladimir Putin: Very well. This programme is good, indeed.

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