MOSCOW At a televised debate about Russia's healthcare system last year, a young doctor asked President Vladimir Putin why so many senior officials sought medical treatment abroad - and if the president was one of them. Putin replied he was not.
He said he used the Central Clinical Hospital, a vast complex on the outskirts of the Russian capital where for decades the top echelons of the Soviet and Russian leaderships have sought treatment. But he acknowledged there was a problem with healthcare at home: Russian state hospitals and clinics, even the best of them, were not up to the job.
"Doctors who work at the TSKB (Central Clinical Hospital) believe that the level of professional training, the financing, the equipment, don't meet modern standards. A lot needs to be reformed there," Putin told the audience.
The Kremlin administration now has a solution: Putin's staff have commissioned plans for a new unit at the Central Clinical Hospital, specially designed to treat the country's most senior officials, according to technical plans seen by Reuters and to medical sources familiar with the project.
Two sources familiar with the project told Reuters the building is being planned for Putin and his close entourage.
The three-storey unit will be exclusive with room for just 10 inpatients at a time. It will be equipped with communication systems that are, under Russian law, reserved for the president, prime minister and a other senior figures.
According to the plans seen by Reuters, the new unit will cost 2.9 billion roubles ($48.11 million) to build, with additional expense for equipping it. This comes as budget spending on healthcare for ordinary Russians, while rising, has not kept pace with inflation.
In a written reply to Reuters questions, the Kremlin's property management department said the clinic was being built but said it was for hundreds of state officials whose care falls within its remit, including but not limited to the president and prime minister. The Central Clinical Hospital did not respond to Reuters questions.
Designed for inpatient and outpatient care, the special clinic will include two VIP rooms for patients, each covering 200 square meters, nearly three times the size of the average Russian apartment, according to the plans. There will also be large conference rooms where officials undergoing treatment can convene meetings, and a swimming pool.
The need for top-quality homegrown healthcare for people in Putin's entourage has become more pressing after the West imposed sanctions and travel bans against some of the Russian elite in response to the annexation of Crimea, two physicians told Reuters.
At the same time, Putin and some of his close allies are reaching a time of life when they are, statistically, more likely to get sick and require more medical interventions.
Reuters has no evidence that Putin, who has made regular public displays of his manliness, or any other senior officials are ill. Nevertheless, Putin is now 64 and if he stays in office until 2024, which is as long as the constitution allows, he will be 71. The World Health Organization gives the average life expectancy for a Russian man at 60 as 15 years; in the United Kingdom and United States it is 22 years.
The average age of the first wave of Russians put under sanctions by Washington over the Ukraine crisis - a list that provides an approximation of the people closest to the president - is about 63.
The main campus of the Central Clinical Hospital, sprawling over a 180-hectare park in suburban Moscow, is operated by the property management department of the Russian presidential administration. Soviet leaders Leonid Brezhnev and Mikhail Gorbachev underwent treatment there. Putin's immediate predecessor Boris Yeltsin was treated at the hospital after heart surgery.
Under Soviet rule, the hospital offered Russia's finest doctors and the most modern equipment available. Alexander Nikolayev, who was chief doctor from 1995 to 2004, said average life expectancy for the top Soviet bureaucrats treated at the hospital was 20 years higher than the national level. "It was ideal healthcare," said Nikolayev.
But the quality of care has declined since the Soviet Union collapsed, current manager in one of the hospital's departments told Reuters on condition of anonymity. The staff are less well qualified than in the past, and the equipment is no longer the most modern, said the manager. For example, the hospital does not yet have so-called "cyber-knife" technology that allows the targeted treatment of cancerous tumors, though some Moscow clinics do have the technology.
The Kremlin property management department said the Central Clinical Hospital remained at the cutting-edge of medical science.
Nevertheless, some of Russia's elite went for treatment abroad, or started using domestic high-end private clinics. A Reuters reporter who visited one of Moscow's most expensive private clinics in November saw several bodyguards equipped with earpieces waiting in the lobby for their bosses, and a line of luxury limousines parked outside.
But two sources close to the Russian government said that these clinics were not suitable for the top echelons of officialdom because they lacked the necessary security provisions.
The presidential administration is seeking to remedy this, starting with the most exclusive patients, according to the documents seen by Reuters and medical sources. Plans for the new block at the Central Clinical Hospital state that it will be equipped with "presidential communications" and "government communications" to ensure occupants can stay in touch securely in an emergency.
According to Russian law on communications, "presidential communications" are provided to the president, the prime minister, the defense minister and the chief of the military's general staff. The president can add other officials by issuing a decree. "Government communications" are assigned to senior officials in government headquarters and ministries.
The documents seen by Reuters also state that the new building will be for "subjects of state protection."
State protection, according to a law covering this area, is allocated to past and serving presidents, members of their families, and seven officials: the prime minister; the speakers of the upper and lower houses of parliament; the chief judges in the Supreme and Constitutional courts; the prosecutor general; and the head of the Investigative Committee, the state body that investigates major crimes. Other people can be added to the list at the president's discretion.
The Kremlin's property management department said construction of the new building was "planned" as part of a federal investment program and that technical plans for the project had been completed. It said the cost of the project was yet to be determined.
Two former employees of the Central Clinical Hospital who remain in regular contact with staff there, and two sources in medical circles familiar with the project, said all indications are that construction will proceed. Another source familiar with the project told Reuters that as of December 2016 the plans were undergoing building permit approval.
Under a provisional schedule set out in the documents, final plans should be completed in 2017, and construction of the new building should be finished in 2020.
Some details of the new building appear in publicly-available documents posted online as part of a tender for consultants to work on the project. The details about presidential communications do not appear in those documents.
Asked by Reuters if the clinic was intended for treating the Russian president, prime minister and most senior officials, the Kremlin property department said: "The construction of the new block of the clinic-polyclinic department is planned for providing medical care to patients whose care is the responsibility of the property management department of the president of the Russian Federation."
It said that group included the president, members of the government and top officials but also staff of other state institutions who total hundreds of people.
Asked to confirm the number of patients the clinic would accommodate, and whether it would have presidential and government communications systems, the property department said: "That information does not correspond to reality."
The department's spokeswoman, Yelena Krylova, declined to specify which piece of information the denial was referring to.
The new building will be linked by underground passages to adjacent blocks, according to the plans seen by Reuters. In one of those buildings - the hospital's main block - rooms for VIP patients on the fifth and sixth floors are also being refurbished, said one staff member and a doctor who used to work there.
Public tender documents for the refurbishment work indicate they will have the sort of communications used by the Federal Guards Service and national defense and security agencies. The main block currently houses general treatment wards. Reuters reporters were not able to get access to the floors where the work is under way.
The other building near the site of the proposed new clinic is block 9, the hospital's radiology department. A doctor at the hospital said there was a plan in place to extend that department by 2019 and fit it with the most up-to-date equipment.
According to state documents detailing the work on block 9, the new equipment would include so-called "cyber-knife" technology that allows the targeted treatment of cancerous tumors, and positron-emission tomography equipment that can locate early-stage cancers.
Reuters was not able to establish whether the refurbished radiology block would be fitted out with secure communications for top officials.
A helicopter landing pad at the hospital is due for completion this year. And a satellite clinic in central Moscow, a stone's throw from the Kremlin, is scheduled for reconstruction work, according to public procurement documents.
The United States and the European Union imposed sanctions on Russia after Putin annexed Crimea in 2014. The measures have had an effect on some of those closest to Putin, including an old friend, the oil trader Gennady Timchenko, who returned to Russia after years of mainly living abroad.
Timchenko's wife, Elena, had her bank card rejected when she tried to pay for treatment in a German clinic, according to a description Putin himself gave to reporters in April 2014. He said her card was blocked because her husband was under sanctions. Gennady Timchenko confirmed the account in an interview with Russia's Tass news agency the same year.
Josef Kobzon, a Russian singer and pro-Kremlin member of parliament, told Reuters that Italian authorities refused him permission to travel to Milan a year ago because he is under EU sanctions. He was seeking treatment for his cancer, and he said he asked Putin to intercede with the Italian government.
"With my status, to humiliate myself and ask was a source of shame, but in the end they gave me a visa. I've already had two sessions of treatment in Milan," Kobzon said.
The Italian foreign ministry said Kobzon was granted a visa on humanitarian grounds, as allowed by EU regulations.
Putin has frowned on people seeking treatment abroad. Speaking in last year's healthcare debate, he said officials should take a moral choice to spurn foreign clinics. He would "look into" those who did not do so, he said.
Alexei Kashcheyev, a neurologist who practices in several top Moscow clinics, said that officials from government ministries, the security services, governors and the Kremlin had started coming to him for consultations when previously they would have gone abroad. He said he knew this because when they came to him, they brought with them medical notes from foreign specialists. The change, he said, was in large part because of the standoff between Russia and the West.
The Kremlin has in recent years significantly boosted spending on healthcare for the elite. In 2012, its property management department spent 5 billion roubles ($83 million) on building or re-building healthcare infrastructure within its portfolio. That is forecast to have risen to 15.2 billion roubles in 2016, an increase of over 200 percent, according to state spending data.
The Kremlin's property management department did not respond when asked about the reason for the increase.
At the same time, spending on the state-provided healthcare used by most ordinary Russians has risen more slowly. It is up by 32.9 percent between 2012 and 2016, budget data shows. Consumer price inflation in the same period was 50 percent.
Olga Zheludkova, a professor at the Research Institute for X-ray Radiology in Moscow, said she did not have direct knowledge of what was being planned at the Central Clinical Hospital, but she said sanctions were returning Russian healthcare to the kind of two-tier system that existed under Soviet rule.
"There are special, elite projects for treating the highest echelons of officials, while there is a lack of quality treatment for ordinary people," she said.
(Additional reporting by Antonella Cinelli in Rome, and Anton Zverev,; Andrey Ostroukh and Darya Korsunskaya in Moscow; Editing by Christian Lowe and Richard Woods)