Navalny Circles: Healthcare (full version)

Friends, thank you very much for coming

today to meet with me and my team, because

for us it is fundamentally important

to maintain an ongoing professional

discussion on various issues.

Today we are talking about healthcare,

which for many years has commonly been described

as languishing in poverty, but

in recent years in Moscow it has had money,

and yet it still continues to languish. In

Moscow healthcare, over the past

few years, 900 billion rubles have been invested. But we

still see

dissatisfaction both from doctors and

from the public. And we can see that

our basic indicators—treatment outcomes,

prevention, and all the other metrics—

are not improving. Today I would like to talk

about what we need to do

to make medicine closer

to people. What do we need to do so that

people feel that a doctor is not

someone from another planet, not

some kind of administrator, and not just part

of a medical system headed by the

head of the health department,

but rather the person who

actually treats them, someone they can

turn to personally in order

to know, um, how to treat their children,

how to care for their elderly parents, and so

on, and so forth. How can we make sure

that medicine truly heals

Moscow residents. And that Moscow residents are satisfied with

their healthcare. All right, let me say a few

words, yes. We have gathered here

because we see you as, well, so to

speak, a likely future mayor. And, uh,

so to speak, we expect something from the authorities. Well,

strictly speaking, I can speak for

myself, I can speak about my circle of

colleagues and friends, I can speak about those who

signed a certain document that we

once called the Declaration of

Independence of Russian Doctors. And that

is not a very large number of people—about 3,000

people—but still, it is a certain

number of people. I can say what

we expect from the future authorities. We expect,

above all, professional autonomy.

That is what I would like to have for myself,

right? And, so to speak, I would not want to see

you as my boss,

and I would not want to see the health department

as my

boss either.

I would like doctors to be

given the opportunity to practice

medicine. Yes, medicine and

healthcare are two somewhat

different things. They overlap in many

ways, but healthcare administration

is indeed handled by officials,

who approve public vaccination programs,

approve or do not approve certain drugs,

authorize or do not authorize

instruments, open clinics, and so on,

yes. But the doctor-patient relationship,

here in the studio, we actually have two

practicing physicians, Leila and me, right?

So, we talked it over and

immediately agreed on this point:

the doctor-patient relationship should, as far as possible,

be allowed to develop

on its own. You see, colleagues, if you

agree with what I am saying, then—uh,

and if not, then—

Excuse me for interrupting, I just wanted

to ask: won’t this lead to a situation where

doctors become a kind of closed-off,

and patients, if they are dissatisfied with something,

will not even be able to complain? And right now

we already have a situation where

patients, well, practically cannot

appeal various possible

medical errors or simply negligent

performance of their

duties. If there is no

oversight at all, if we remove any

administrative intervention from

this, then it will turn out that the medical,

the physicians’ community, is completely unchecked.

No, you see, this is not about

eliminating all intervention. Nor is it

about saying that we can immediately build

an ideal system. We need to start

moving in the right direction.

The right direction is the direction

of freedom; it is the direction of lifting

restrictions. The current system of

restrictions is structured in such a way that

bad doctors are not prevented from doing

bad work—we know this

and see it—but good doctors are prevented

from doing good work. Of course,

any freedom carries the risk

that someone will abuse it,

yes, but as things stand

now, this is not freedom either, and,

so to speak, it is not good. When

I say that, uh,

freedom means we should not treat

every doctor as a potential

drug dealer. I am not a drug dealer. I should be

allowed to prescribe to patients

with cancer or

any other condition whatever I consider necessary,

namely opioid analgesics. Am I right

in understanding that the role of

professional communities—that is,

self-regulating organizations—should be strengthened, and that

intervention by administrative bodies is not always

necessary? Doctors themselves

organize into a community, they feel

responsibility to one another and

to patients, and regulate such

matters themselves. Indeed, well, they ought

to feel that way, in my view. And so

Here I completely agree.

With Maxim, and I’ll probably start with a different

topic, which is probably also worth

discussing. It is specifically the issue of

the professional training of doctors. It

includes not only an understanding of

how a patient should be treated, that is,

the actual set of medical skills, but also

more broadly, the things we talk about

in relation to all

professions. This includes a doctor’s self-respect

and an understanding of their place

in the hierarchy Maxim is talking about.

In other words, for a doctor to

meet all the necessary standards, this

must be built in from the outset, both in

education and in the formation of such a

doctor. A doctor must respect themselves

and respect the patient. From that will grow

this understanding of

the need for freedom. Unfortunately, I

think that today there are a great many

doctors who do not really

understand that this freedom exists or what

to do with it. There are people who

have been boxed into the limits of

the conditions in which they work, conditions of

frankly indecent salaries, in any case.

A doctor, a young specialist,

who goes to work at a respected

clinic in Moscow—I only just yesterday

spoke with a Candidate of Medical Sciences

who, in my view, has very good

prospects. I’m judging this as someone from

an older generation, yes, and I would like

these doctors to take up this

baton. And he tells me that

his salary is 14,000 rubles (about $150), while

the salary of an orderly in that

clinic is 17,000 rubles (about $180). You do not need to make

any complicated deductions to

understand that doctors have effectively been

left to a system in which

patients will “thank” them, bypassing

the official channels of payment, so to speak.

Yes. And we are not talking about private

medicine; we are talking now about

state healthcare. Here I absolutely agree both with

you and with Maxim,

because the current system of this

excessive and strange state

regulation, and above all simply

statistics that are being manipulated, leads

to a situation where doctors often

simply have to falsify

statistics in order to

earn more. They have to invent more

insurance cases out of thin air,

just write them in so that they can

get paid. And instead of treating people,

they are occupied not with healing people but with paperwork,

just producing papers for the Department of

Health. Yes. And there is one more very

important thing we need to understand,

yes. And I actually would not like

us to focus on money, because

it is so customary: doctors come and

complain that they are underpaid, right? It is possible

to earn decent money in medicine, yes, and

so on. But that is not the point. They should

be paid more. But first and foremost

we need to talk about the doctor as an

independent legal and

economic entity. Right now, a doctor

is not really anything in their own right. Not an object,

not a subject, so to speak. A footballer,

for example, signs with a team.

Excuse me. I would not want

a doctor to be viewed as an

economic entity. As a

legal one, perhaps I would agree. But

why an economic one as well? We can

bring some Brazilian footballer to a team,

but why can we not also allow ourselves to

let a doctor, please, in the end,

act independently? Give them freedom, give

them the opportunity to be an independent

legal and economic entity, and then let

doctors themselves build

their own relationships. Patient: that immediately raises a lot of

questions. I mean, I’m actually not a

medical professional; I’m just an ordinary patient. Well,

you look like a healthy patient. That’s not something I

need just yet. Yes, all right, not an IV drip yet.

No. But you are talking about a free

economic entity. Here is a simple

question from someone who is, of course, not connected with

your profession. Where does the money come from

for you to hire

a radiologist?

A radiologist for 100,000 or 200,000 rubles (about $1,100–$2,200).

If we are talking about compulsory health insurance, then it is clear that

a completely different

principle of budget management applies there. So how

is that issue resolved? You know, this is

slightly outside my area, yes? I apologize.

That is exactly why we are going to

elect a mayor.

What I can tell you is that, once again, there is actually a lot of money

in Moscow’s healthcare system.

We spent on the healthcare modernization program

alone

100 billion rubles (about $1.1 billion). We purchased

a huge amount of equipment—

ultrasound machines and CT scanners. Right now there is no one

to operate them. That is why I say that first and

foremost we need to invest in personnel,

because if we have scanners worth

$3 million just sitting there

under a dust cover, with no one to operate them,

then what exactly are we investing for? Yes,

absolutely. And, so to speak, when I

was taking people around—you see, we have something a bit like

Saudi Arabia here: an enormous

amount of very expensive, very expensive

equipment that no one knows how to operate.

Yes, you go to a clinic in Boston, and there

you see a machine, and they tell me, well,

I brought doctors from Moscow there, and they

said, "Oh, we already have 64-slice, 128-slice scans there,

while here they only have four-slice ones.

Seven days a week, 24 hours a day, while ours

works only until 3 p.m., with a break.

And the main thing is the report we get here—

what exactly are we supposed to do with it? But here

we get a professional assessment specifically of the

equipment you’re talking about.

Unfortunately, having some familiarity

with private clinics in Moscow, including

some fairly high-level ones, I’ll say

frankly: I don’t trust

the results they produce. In other words,

the same high-end

medical technologies may be there, but here

overall there is a lack of professionalism, and it depends on

the tasks managers set

for doctors.

But managers shouldn’t be setting tasks

for doctors. A doctor’s tasks are set, so to speak,

by life itself. Right? A sick person simply comes in—

that is the task.

The key phrase here is a doctor’s freedom. A doctor’s freedom

implies private medicine. Can

a doctor work as an independent

practitioner? Of course, by all means. Absolutely. But

why is it that today he doesn’t have that

opportunity? He can work, but he can

only be incorporated into some

organization. In other words, he

joins some organization,

and in practice that becomes a closed subject. If he’s not

particularly proactive in that sense, then he

simply won’t get involved in this whole business of private

practice, because it is

frightening simply by its very structure.

That is, just imagine

that a doctor could have, in the evening,

after his main job,

a private office where he would

practice. That’s probably unrealistic.

Simply because doctors, I’ll say it again,

are generally not

businesspeople, and to get into all of this

is insanely complicated,

it’s almost—almost impossible. Well,

on this point I completely agree with

Maxim: yes, we really do need to clearly

understand healthcare as a system

for delivering medical care, as

management, and the treatment of a patient as, well,

a function

of the doctor’s vocation. Those really are two

different things. And the situation that, well,

I, for one, can clearly see is that we

really can install

magnificent equipment of any

European standard, but to operate

it, unfortunately, there’s no one. And

that’s the situation. I entered medicine

back in the 1990s and left

medicine in the early 2000s. And

from what I observe now, judging by

the level of what is happening now,

professionalism is declining, unfortunately. That’s

a fact. And, incidentally, it’s not

just about salaries. In fact,

here too I can agree with my colleague

that in principle a person can earn money

perfectly honestly, without taking any kind of

under-the-table payments. No, they can earn. It’s

simply not true that salaries are

everywhere in Moscow hospitals extremely

low. No, if you go to a private

clinic, then yes, probably. But

in the state sector—

there’s only one way. No, of course I’m not

talking about public healthcare.

I’m saying that a doctor who wants

to change things can, yes, indeed,

move into private healthcare,

go into private medicine and earn—

Excuse me, speaking as a patient: you say that

a doctor can earn more by going to a

private clinic. And again, you still haven’t

answered. I still want to hear from

someone where the money comes from

so that medicine outside the private sector

could make the kind of choices you’re

talking about—hire any specialists, pay the

salaries they deserve. In other words,

again, if you’re saying that

you all move into private medicine,

where things are good for you, then I’m left here with my

condition and no one to treat me. These are crucial issues.

No—may I finish? So there is

a kind of framework. Right now we have

the compulsory health insurance system (OMS), yes, and we also have

the system of private clinics. For now, that isn’t

changing. So within the framework of what

exists, do you see a solution to the problems

you’re talking about—problems connected with

professionalism, pay,

the ability to earn, the ability

for doctors to be independent—or does this

require some different model,

above all a different financing model? No,

look, it seems to me that we need to

move gradually, right? We’re talking

about where to begin. Not in a year, not

in five years—it’s impossible to solve all problems

at once. We need to start with

some simple measures, so to speak:

stop looking at doctors as if they were

drug dealers. First. Allow them

to prescribe what they believe is necessary. And

get rid of the enormous amount of paperwork,

multiple signatures on sick leave forms,

and so on. Stop

treating everyone like crooks. Yes,

crime has to be fought, of course, but

fight it when it has actually

been committed, so to speak. There’s no need

for this excessive

preventive control,

right—abolish this, that,

and the third thing; there are very specific measures.

Yes, focus on medical education,

make medical education more

attractive to people.

To intelligent, educated people, yes, because the level of

medical students, well, actually,

yes, that is

a separate story. So, uh, well,

more English, more mathematics,

there are quite specific proposals there,

yes, start moving in the right

direction. After that, there is no need to immediately

break the compulsory health insurance system, no need to immediately—does it

satisfy you within the CHI system? No,

of course it does not, you understand? A lot of things

are unsatisfactory. I do not know how it

works. That is, we do not know—it is some kind of

fiction. It exists, supposedly. For the patient

with people

just ask: have you used it

just imagine, I practically do not

go to—no, you understand, within this

system, with quotas and everything else,

a great deal can be done, yes, and

it is possible to adapt somehow. I am against

reforming everything at once and

changing it all immediately. People are used to one thing;

we need, we need to remove restrictions one

after another, and, so to speak, understand, uh, what

our priorities are. Medical

education, uh, the doctor as an independent

actor. That does not mean that tomorrow he

will suddenly be vested with everything. We will buy him

insurance. If we have there

an independent actor, then how does that

fit with the CHI system, where there really

will always be economic standards?

Otherwise you cannot—may I interrupt you?

I am sorry. The point is not that right now

the whole world does not revolve around the CHI system.

The CHI system is simply a way of distributing

money. We simply need to understand clearly

that Moscow has money for healthcare. In

Moscow, for every Muscovite there is

four times more money allocated to healthcare

than for any other citizen

of Russia. And if we introduce the principle that money

follows the patient, we need to understand

that you as a patient, I as a patient, as

an ordinary Muscovite, all of us have

a little bag of money allocated from

the budget. We simply need to give each person

the right to carry that little bag of money

to any doctor we

want to see. And I would like, perhaps,

to turn our discussion a little now

toward, uh, your

area of expertise, our key proposal

in our program on expanding the network of

outpatient clinics and

moving toward making sure that

clinics are accessible, which more likely

means not building huge

new clinics, but bringing doctors closer

to people. Right now, under the standard, for a

general practitioner appointment, 8 minutes are allotted. This is

absolute madness. It seems to me that we need

not to suffer from gigantomania, but to do it so that

the city would rather rent

small offices in residential courtyards. After all,

we can place a doctor, this

independent, free doctor, in

every courtyard, rent a space,

put a general practitioner there, a family

doctor, equip the office there with

an ultrasound room, a small staff, and

make it so that on average, for every 1,200

Muscovites, there is one doctor who knows

that Muscovite personally, knows their family,

knows their history of chronic

illnesses, and so on, so that I know

exactly who my doctor is and that my money,

which is assigned to me—I could, if

I trust the doctor in my courtyard, I could bring him

that money. If I do not trust him,

I go to the next courtyard and take my

money there. In other words, we want to move

healthcare much closer to people, so that

the distance between you and your

regular general practitioner

is very, very short.

A good, wonderful idea. I believe

that, overall, it is not even very

new. But I return again to my point: where do we get

the doctors who, for you as a patient,

will be satisfactory—like that family doctor

who will satisfy you with the quality of his

medical knowledge and his ability, in general,

to treat people? So, returning to this,

I absolutely agree again with Maxim,

that without breaking what exists

today, but adding something brick by brick

to it, so to speak, constructively,

we still, as everywhere, as in

everything in our lives—and healthcare is

only the topic of our discussion today—

need to return to

education. Well then, tell me, do you agree

with the statement that our medicine,

our medical education, is somehow

stuck at the level of 1960? Absolutely.

My son studied from the same textbooks.

He studied at the Second Medical Institute

(a former Moscow medical school). Well, now it is called

RSMU, or RGMU, whereas in my time it

was called the Second Med. In many

specialties, they were using the very same

textbooks that were used when I was a student.

Yes, in medicine, generally speaking,

knowledge is updated, well, every 5

years or so, you understand—though it varies

by field, of course. There has been a kind of

negative selection, yes, among

the teaching staff, so to speak—the weaker ones

very often stay behind, yes, they remain

to teach at universities, and so on. So

the number of problems here is simply enormous,

yes, so to speak, and you mentioned

professional communities,

but there are no professional ones yet

communities, and no one is allowing these

professional communities

to develop. Uh, so to speak, officials

immediately take the initiative into their own hands, and

if they need to create, say,

a professional cardiology

community, they just appoint one right away. That’s not

how it grows, you know, so to speak.

The best scientist is not the one who was

appointed the best scientist, right? It’s the one

who has the best results and who

is recognized by the professional community. And

in some field, a strong community may emerge in 5 years,

while in another it may take

20 years. Well, that means

that’s just how it is: you have to be patient, you have to wait, you have to

cultivate all of this. In that connection,

and in light of what you’re saying,

I wanted to get your assessment of our

proposal in the area of, well,

the fundamental, uh, the fundamental

part of healthcare, which

is that at least

40% of the money that goes toward

endless capital expenditures, toward

modernization, and the purchase of new

equipment, should instead be

invested in doctors’ education so that

in 5–7 years

we start seeing results. Because a modern doctor is

a doctor who absolutely

must speak English.

A modern doctor is a doctor

who may have studied abroad for a year or two,

and so on and so forth. In other words,

if we now take some of these

billions that we definitely have

in the Moscow city budget and invest

some of that there, without even worrying that

medical universities are federally run institutions.

It doesn’t matter whether they’re federal institutions or not.

We still have to treat Muscovites

here, in our city. That’s why we want

to invest enormous sums in training doctors.

We have that money. Yes, that’s

a wonderful idea. Yes. As for

opening these mini

clinics, these offices in every

courtyard, again, that possibility should be allowed,

but it shouldn’t be mandated, right?

You shouldn’t order that this office must necessarily be staffed

with a specific roster, fully manned, and so

on. Because then, you see, I

from my own experience working in Tarusa (a town in Russia),

well, fortunately, I found my friend

and colleague Artemy Nikich Okhotno quickly.

I had been watching his development there since about

his fourth year of medical school, and the next

therapist I managed to recruit and

bring there, to Tarusa, only some

4 years later, you understand? So yes,

so to speak, we endured, waited, searched. Uh,

it’s very, very difficult, yes, very difficult

to find a good one. Everyone understands that finding

a good writer, scientist, musician, or doctor

isn’t as simple as just whistling and paying. No.

But in Moscow, after all, the staffing

problem with doctors is not as severe

as it is in the rest of the country, because

this has a negative effect on the country

as a whole. But Moscow does siphon off

the best personnel, at least from

the nearby regions. And it seems to me

there isn’t a massive shortage

of doctors in Moscow—or is there, after all?

What do you think? It depends on the

specialty.

It depends on the specialty. Depending

on the specialty. You have to

understand that, again, say,

there’s no enormous shortage, no. I mean,

to say that Moscow’s operating rooms will

close tomorrow because of a lack of

anesthesiologists? No, of course they won’t.

But, for example, there is a shortage in

anesthesiology and resuscitation services,

quite clearly. And in terms of staffing

there are major problems. And if

we’re talking about a specific, uh,

area within anesthesiology

and resuscitation, then the situation there may

be even worse. For example, I

just know of a fairly specialized

department where, when I left, the

standard team consisted of two doctors

and, well, usually an intern or resident.

Now one person is on duty. Well, let me

go back to what you were saying about

education and staffing, because, well,

there was the question: will the patient

actually like this doctor? And here I

return to my role as a patient, yes,

because I don’t know how this is structured from

the standpoint of training, but I do understand that

from my point of view as a patient, the

main problem with training, aside from

textbooks from the 1960s, is

the complete absence of any ethical

component, any ethical dimension, in that

training.

That’s very hard, very difficult

to teach, you understand? To cultivate

a soul in a person is very hard, yes, and a course

But this isn’t a question of the soul; it’s a question of

basic standards for how to treat a patient.

Some kind of

rules, essentially, yes—what you can and cannot do

in how you behave with a patient. We won’t even

get into how much this is taught on a residual basis

in medical school nowadays.

Many ordinary people far removed

from medicine view doctors as

some kind of, well, mafia, as it were: they

don’t expose one another, don’t turn one another in, like

housing maintenance office workers (ZhEK, Soviet/Russian municipal housing services) who stick up for each other,

and doctors are seen the same way. No, well,

of course doctors cover for—What did he do there?

How many pairs of scissors he left behind in your stomach,

his fellow doctors will never turn him in.

That’s a problem too, right? Well, well,

yes, it is, but again, that issue too,

can’t be solved just like that, you know? There’s

also one more very important point here. I

know that some of those

present will disagree with me, but we need

to understand that medicine, generally speaking,

medicine itself is not a service

industry, right? And I insist

on that, yes, because in the end you can

reduce everything to the idea that there is

production and services. You could

say that a priest’s work is

spiritual services, and a teacher is

providing educational services, and so on,

yes, but that only offends people and

that’s all. But in fact it not only— not only,

so to speak, offends people, it also

creates completely wrong

relationships, yes.

prescribe—what can I do for you—that’s

wrong.

Naturally, a patient would like

it to be a service industry.

Of course, there is a service component,

you see; schools have one too.

There is, so to speak, a component there as well:

the hallways should be clean. A patient would like—

doesn’t want the doctor to talk? Let me

let me tell you, as a patient, what I

want first and foremost. I want

to understand what is being done to me.

Why? I want people to talk to me,

to explain their actions and, essentially,

for me not to be in the position of some

silent idiot on whom various

procedures are being performed. The doctor should

understand what is happening to you. I

hope the doctor understands that. No,

first of all, very often they do not. But

secondly, you see, what you want—

what you mean is: "I want the doctors

I deal with to be sensitive,

subtle, deeply empathetic people,

you know? Well yes, of course, we all

want that."

nivakatsiya

at the very least

what it means, at least, why they prescribed it to me

prescribed it.

That is exactly why we are proposing this

crucial principle: the money follows the

patient. Doctors are people too; they are different.

Some are more sensitive, some less so.

Each of us should have the opportunity

to refuse this doctor and go to another.

If your local clinic has some awful

woman who yells at everyone, then you

leave and take your money with you. And that

woman who yells at everyone—she

understands that patients are leaving

her, and she won’t receive

anything. This is crucial, and we can

do it right now. I would like,

perhaps, you know, to briefly touch on

something concerning, in general,

the structure of healthcare in Moscow. In my

view, we still have

a medical infrastructure that

is based on principles

from the middle of the last century, when the main

threat to health was considered to be

infectious diseases, and there was this kind of

mobilization-style medicine. Let’s

treat those who—wash your hands before eating—

wash your hands before eating—and treat huge

numbers of people who suddenly

came down with, I don’t know, bubonic plague.

Uh-huh. Now the main threat to health is

the diseases that cannot

be cured in two weeks.

Cardiovascular diseases,

cancer, and so on and so forth.

Therefore,

we really need to move to a system

in which a specific doctor treats

a person over a long period—well,

for months, years, and so on—and gives them

ongoing advice. That is much more like

the kind of doctor you can come to

and actually talk to, someone you can

tell: "Yesterday it was like this,

today it’s different." But our, our system

is geared toward the idea that most

illnesses are supposedly something where you

need to get to a brilliant doctor

who will cure you in a week or two.

But modern diseases

are not something that can be treated in a week or

two, right? Well, perhaps such an

idealized model is possible. Only if

we speak about our realities, still,

well, I, as someone working in private

medicine, would still distinguish between,

probably, the capabilities of public

healthcare and private

healthcare. And here, private does not

necessarily mean some kind of VIP medicine.

It too can be accessible for many, many

people in Moscow. But here the question is

that those very funds in the

bag that you were talking about, as I

understand it, can circulate both into

private medicine and through voluntary health insurance, right? As

a patient, I want to see a doctor. What

difference does it make to me where I pay that money?

And if the state has guaranteed me the

money, I can give it to either a private or a

public doctor. There is

no difference. But here we must not

forget one more point, namely what

we are talking about. You see, medicine

is not all the same. There is planned care. Well,

what we are, in fact, talking about now

really is something with which I probably

completely agree. Yes, absolutely,

A person should probably be treated by

the same doctor, well, roughly speaking, for their entire

life. Well, as far as that is possible,

but there is emergency medicine. And this

situation

is a situation that requires fairly

strict government intervention

and fairly strict government

regulation, because this is

a matter of state security. And here, uh,

it is absolutely not

well, for a megacity like Moscow,

well, say, the Perm tragedy,

the Lame Horse tragedy (the deadly 2009 nightclub fire in Perm) is, unfortunately,

a very real possibility. And

here, uh, this is precisely

mobilization-based healthcare.

It is simply, uh, again, ambulance services,

emergency medical care, emergency

medicine—this is exactly mobilization-based

healthcare. It is healthcare

that must be built on a very

almost semi-military principle. Alexei, I

have this right—may I ask? Am I right

in understanding that you also believe, as

Leila was saying, that some basic

simple things, not especially

high-level perhaps, but still

patient-oriented, should remain

fully within the compulsory health insurance system, and everything else should be private

medicine, or not?

I believe there is no contradiction in that

whatsoever. We simply need to—look,

the city has a large amount of, well,

medical services available, doesn’t it? No? Do you

think it doesn’t? I think it does. There is

insurance. This insurance covers

medical care. It covers

our healthcare needs.

It doesn’t matter which doctor you go to. The main thing

is that behind you there is that proverbial

bag of money. And you must know for sure

that the state will cover both your

medications and your treatment with any

doctor you choose to see. That’s

all. And given that private clinics

even have different prices among themselves, yes, you

understand that this bag

will pay for an appointment at one place at

one rate, and at another place at another. That is

your choice. If you want to see

the most elite doctor in

Moscow, the nicest possible one,

but whose appointment costs three times as much—that

is your choice. No, the money for health insurance is not something you are paying for

for the rest of your life

for medical care as if—no, not for

the rest of your life, just for a year, that’s all

—money. I agree with Maxim. So there are two

things: education and the economic model.

The economic model may even be

the primary one, because it is the principle

by which the structure is organized. How exactly it

works, why, what mechanisms will make it

function—I haven’t heard that. I don’t understand.

This is actually important to me as a

patient, because based on this

today I understand where it is safe for me to go

and where it is better not to venture.

I would like to understand what kind of

model is being planned there—is there any version of an

economic model? How is it being decided?

Still, healthcare as a model, especially

healthcare in Russia, cannot

run on market rails, and it

absolutely does not run on market principles.

Rather, I would speak about infrastructure.

You see, whatever the current situation may be from

the standpoint of the economic model,

perhaps, from that perspective, we should not invest

huge amounts of money in training doctors. But from

the standpoint of reason and development, we

must invest huge amounts of money in

education. Because what does the economic

model tell us? If we

spend 100 billion rubles (about US$1.1 billion) on training

doctors, most likely they will simply go off to

America, because salaries there are

higher. But from the standpoint that we

need to treat Muscovites both now and in 10 years’ time,

we need to invest money in

medical education. What kind of long-term

economic model do we have? If for us it is all about the here

and now, and this is our last term,

and after that we need to get out of here quickly, then

that tells us that the economic

model really does matter, that is, there

must be some mechanisms built in. It is not

just about how much money we are

specifically going to pay for this. It is not just a bill.

But I clearly agree that it

must be long-term, and then

it turns out that everything we are talking

about is primary. The problem there

is with standards. In fact, it is

a problem because the standards that

the standards that have now been written out, yes,

however else to put it, they simply

have nothing to do with

how they can be implemented within this economic

model.

It is hard for me to explain how it could work, but I can

describe how it looks to me

right now. So at the moment, those very

notorious standards that doctors

are all howling about now.

I want to say myself that as recently as five years

ago I was saying that the trouble with our

practical medicine was the lack of

standards. And now it turns out that

the road to hell is paved with good

intentions. Because the standards that have been handed down to

us, which are mandatory for

us to follow, are simply not

workable in some specialties. Let’s just say

that some people may be producing

slightly more reasonable ones, while others are

completely hellish, right? There is nothing like this anywhere else in the world.

What is being done, what we refer to here

as “standards,” is something entirely different. It is

a document a page and a half to two pages long,

consisting of a table that includes

items like 0.1, the frequency of service provision, and

so on and so forth. It has absolutely nothing to do with

medicine.

It has to do with planning, yes,

so to speak, yes, indeed,

the state must, must, yes, yes, and

it is mandatory. So it,

yes, well, you see, in our system planning,

planning in medicine is really

forecasting. But in our case

forecasting has, so to speak, been replaced by something else.

They ask you how many

tests you are going to perform next year, say

200, right, and if you do not do them,

if by the end of the year you have only done 100, then go and draw

blood from whoever you can, because you have to

use up those reagents, right?

If you did 300, then you will be punished for

not having done 100. So this

simply has to be abolished. So when I

say abolish it, abolish all this,

abolish this kind of planning, when I speak about

freedom, abolish this so-called routine health screening

(dispensarization), this foolish thing, yes, it is simply nonsense, it is

a fiction, it does not work at all. And all of this

simply needs to be stopped, abolished,

and in a sense we need to start almost from

a blank slate. The alternative,

probably, at this point, again,

if we are talking about an alternative, would be

to break the whole system all over again. It has already been

broken once. And now, in fact,

those of us who work in clinical

practical medicine are precisely

living among the ruins of what was already

broken. Or rather, maybe not broken—

it was destroyed. Listen, let us not

cling to these myths that there once was

some kind of great Soviet

medicine. I studied from 1980 to

1988. As for buying medicines—yes,

no, listen, listen. Well,

colleagues or not, I went through all of this,

and I have read all of it. You see,

the lag began, if we are talking, so to speak,

about our medicine falling behind,

it began in the mid-1950s with the Doctors’ Plot

(the anti-Semitic Stalin-era campaign against doctors). We are talking about the Moscow

healthcare system. We proceed from the fact

that we have mandatory

health insurance. In addition, the

Moscow budget contains a huge

amount of money allocated for

capital investment, major repairs, and so on, and

so forth. We need to discuss how

to spend what we have within the current

imperfect system. Well, of course,

here I am again pulling the blanket toward

education. And education in this sense

means not only the younger generation, yes, but also

this so-called continuing

professional development that we have,

which in our case is also an entirely formal

exercise. You see, every five

years we receive a specialist certificate,

we renew it, but it all comes back

to exactly the same place. In other words, keeping up with

broader global

trends in medicine, unfortunately,

without knowing English, is simply

impossible. But even so, let us suppose

that if one approaches it

in a serious, fundamental way and devotes to it effort and

material, moral, and

time resources, then it would still be possible

to move things forward, well, at least to some

extent. All of that would be better than

the way things are now. I completely

agree with you. Suppose we have an excellent,

properly trained, wonderfully

educated graduate. But that does not yet

exist. Well, wait. Just

wait. When that person does exist, and when he is

also given freedom, then we will need

to see what he does. We have not yet reached

the point of freedom. So far, we have only begun with

education. No, we said education

and freedom. Freedom without education is

a dangerous thing. Indeed, that is exactly

what we were really talking about today,

yes. Education without freedom is

useless, yes, because you cannot apply it

anywhere. So what we need is education and

freedom. I wanted to briefly touch on an

interesting issue and get

your opinion as professionals on

this subject. Not long ago, the chair of the

Supreme Court spoke about

bribe-takers in the country. And it turned out that

the main bribe-takers in the country are

teachers and doctors. They are the main villains,

the ones from whom, supposedly, everyone suffers most—

traffic police officers, teachers, and doctors.

And this leads to the fact that, indeed,

the image of a doctor is often that of someone

who, well, without a bottle of cognac

or an envelope of cash, will never do anything

for you, and that this system does not work

any other way and never will. So

what do you think about that? Well, what do I

think about it? I think that it is

not true.

I do not think so. You see, I

can speak for myself and for my

colleagues, but that is not how we work. That is

really all I can say. This does exist in our

environment. After all, in our country

there is quite a strong stereotype

of the doctor as a villain. And as we can see

now, including from the state,

as an extortionist, yes, and they even say so themselves,

that it is not us, the officials, who are the extortionists, but rather

yes, of course, we do have problems,

the officials say, but the main culprits, of course, are...

The extortionists are doctors across the country.

Let's be honest, this really is

a fairly widespread phenomenon in many

clinics. These are the kinds of relationships

that have taken shape. And it seems to me that all this time

we've been talking about the same thing. All

our problems come down to one thing: how

this is structured from the standpoint of, excuse me,

economics and process organization. It's all

about the same thing. When you were talking

about a doctor who holds a Candidate of Medical Sciences degree

and earns 14,000 rubles at their job, then

that cognac is exactly what we are, right here,

bringing into existence. In a system where

you have 8 minutes to examine a patient, 100

rubles for some procedure that

actually costs more, and a salary of 14,000 rubles, we

naturally create a system of bribery

as a matter of course. It's built into this model,

yes, it's built into it. It's very easy to manage through regulation,

of course; it's a very

convenient model, when everyone is supposedly

guilty, and at any moment it can be controlled in some

way. So this

model, there it is.

It's a question of self-respect and self-esteem, it's

a question, again, of upbringing,

upbringing.

the model, freedom, yes, and self-respect,

all of this comes from the same general place.

That's what I'm talking about: it's mutual. This

stereotype exists too. I was also

remembering a case when

I was stopped by an officer from the

what do they call it now,

traffic patrol service, and he was hinting at something,

and I said, "You know,

unfortunately, I don't pay bribes." And somehow, in the

conversation—though I try not to get into them—

they still keep pressing. They apparently have

methods, it seems,

of neuro-linguistic programming,

where they somehow draw out certain

information. And when the word 'doctor' came up, I was told,

"Well, my dear, if anyone would,

it would be you, wouldn't it?" So there you are, standing there

trying to explain that I'm not like that, unfortunately."

Well, that's all the time we have, friends. Thank you

very much. This was a very interesting

discussion. The key points I took away for

myself are precisely

education and freedom. We need to invest more

of the money we already have

into doctors' education, because we

understand that the return may not come in

a year or two, but it is the kind of return

that is needed—the kind patients need.

Doctors need to be freed from excessive

administrative duties. We need to give them

more freedom so that they can

treat people instead of being constantly

overregulated and doing some kind of

bookkeeping work all the time. Our

healthcare program is

a living document. We are refining it, we are

adding to it. And for us, it is fundamentally

important to have this kind of direct communication

with the professional community. Thank you

so much. Thank you. Thank you. Good luck.

Thank you. Very cool.

[applause]

And this is in his