Solving the Problem of the Provision of Medical Personnel in the Cities of Western Siberia in the Context of the Reform of the Organization of the Healthcare System (1946-1960)

Dudkina Marina Petrovna ORCID: 0000-0001-8758-5272 PhD in History Head of the Department of Organization and Support of the educational process, Associate Professor of the Department of History and Political Science, Novosibirsk State Technical University 630079, Russia, Novosibirsk region, Novosibirsk, ul. K. Marx Ave., 20 m.dudkina@corp.nstu.ru

 The development of healthcare, understood in Soviet times as a branch of the national economy, was naturally tied to industrial and demographic growth.

Since the 1930s, Western Siberia has been experiencing an urban boom, which was a direct consequence of industrialization and the subsequent vector for the socio-economic development of the region. Despite the difficulties of wartime and the post–war famine, accompanied by an unprecedented high mortality rate, over the 15 post-war years, the population of Siberia grew by more than 5 million people, including 1.6 million in the period from 1946 to 1951. At the same time, the growth of citizens was much faster and amounted to about 65% versus 12.7% in rural areas ^{[44, pp. 45-46]}. Therefore, the chronic problem of providing the healthcare system with medical personnel, common to the whole country, was felt especially acutely in the cities of Western Siberia.

For its analysis, three indicators were of leading importance: the number of medical workers, their number per 10 thousand population and the coefficient of concurrency, allowing to assess the availability of medical care for the urban population of the region. Only their correlation with each other allows the most objective assessment of the situation and to understand the effectiveness of certain measures applied. Therefore, the analysis of contradictory processes in the field of staffing of urban healthcare in Western Siberia in the post-war period was based mainly on medical statistics. Some of them were included in the published industry collections. However, the information contained in them reflected only the most general quantitative data, which did not allow to restore the picture in its entirety. Therefore, the most significant empirical resource for the study was the material of medical statistics deposited in the relevant funds of central and regional archives.  To identify approaches and results of solving the problem of personnel shortage in the studied period, the same type of data were taken into account, comparable chronologically and geographically, subsequently summarized in tables.

The end of the Great Patriotic War made urgent the task of organizing full-fledged medical care for the civilian population, which everywhere encountered an acute shortage of personnel.  In the cities of Western Siberia, it has acquired a chronic character. If in the pre-war 1940 in the USSR there were an average of 8 doctors per 10 thousand inhabitants, in the RSFSR - 7.6, then in the cities of Western Siberia, as can be seen from Table 1, this coefficient varied from 2.4 to 6.6. There was a more or less prosperous situation only in the Kemerovo and Omsk regions, where for every 10 thousand inhabitants there were 6.4 and 6.6 doctors, respectively. At the same time, in the cities of the Omsk region in 1940, only 49% of available medical positions were staffed, in Novosibirsk in the last pre-war year, only 5 doctors served every 10 thousand people, in the Altai Territory, where this indicator was the lowest in the region, in 1941 there were at least 300 doctors missing ^{[2, L. 1]}; ^{[37, p. 302]}; ^{[44, p. 112]}; ^{[33, p. 487]}.

Table 1

The coefficient of provision of medical personnel per 10 thousand urban population of Western Siberia in 1940-1960 ^{[34, p. 534]}; ^{[36, p. 108-109]}; ^{[36, p. 115-117]}; ^{[36, p. 155-157]}; ^{[36, p. 167]}

During the war years and immediately after its completion, the situation with medical personnel everywhere showed negative dynamics. For example, 661 doctors worked in the cities of the Altai Territory in 1940, 894 in 1943, 580 in 1945, and only 510 in 1946, which was approximately 77% of the pre–war 1940 figure. Similarly, there were fewer doctors in Kuzbass in 1946 than in 1943 by 183 people ^{[37, p. 88]}; ^{[3, l. 1]}; ^{[43, p. 173]}. This situation led to a high coefficient of concurrency, when the doctor was forced to take a load of one and a half or two rates. If in the USSR the average coefficient of concurrency among doctors in 1946 was 1.5, in the RSFSR it was slightly lower – 1.4, then in the cities of the Tyumen region in 1945 – 2.2, in 1946 – 1.8, in Kuzbass – 1.85 and 1.9, respectively, in Novosibirsk in 1946 – 1.6, in the Tomsk region in the same year 57% of part–time doctors ^{[35, p. 31]}; ^{[4, l. 119]}; ^{[5, l. 3]}; ^{[2, l.1]}. It was they who were entrusted with solving the most difficult tasks to reduce morbidity and mortality.

In part, the shortage of doctors in 1946-1948 was made up for by specialists who voluntarily moved to Western Siberia for personal and family reasons.  This flow was insignificant. The main role in solving the problem was to be played by two sources of replenishment of medical personnel: the return of doctors from the active army and the distribution of graduates of medical universities and colleges to Western Siberia. The ratio of these two flows was not constant, since the peak of demobilization occurred in the second half of 1945 and 1946. Therefore, in 1946, almost half of the doctors who arrived in the regions and territories of Western Siberia were demobilized: 263 doctors arrived in the Kemerovo region, 82 of them young specialists, the rest were demobilized, in the Omsk region from 108 doctors 61 arrived on vouchers from the Ministry of Health, the rest from the army, in Novosibirsk out of 135 doctors, demobilized – 64, university graduates – 30, in the Altai Territory out of 200 doctors of young specialists – 135, from the army – 30. In 1947 and especially 1948, the ratio of flows changes: in 1947 in Kuzbass out of 333 there were 171 doctors who arrived – graduates of the Institute, 33 demobilized, in Novosibirsk there were only 45 demobilized out of 170, in 1948 – 4 out of 204 ^{[42, p. 98]}; ^{[30, l. 1]}; ^{[31, l. 1]}; ^{[31, l. 29]}; ^{[5, l. 8-9]}; ^{[6, L. 14]}; ^{[3, L. 3]}. This made it possible to mitigate the severity of the personnel problem: from the data in Table 2 it follows that, compared with 1946, the total number of doctors in urban settlements in the region in 1947 increased by 130%, in 1948 – by 160% compared to the same year. The number of nurses increased almost in the same proportion – by 120% in 1947 and 155% in 1948. Thanks to this, part-time work in healthcare decreased, but did not disappear. In 1947, in the cities of the Tyumen region, this coefficient decreased to 1.5, in Novosibirsk – to 1.4, in the cities of Kuzbass – to 1.6 in 1947 and to 1.5 in 1948, in the cities of the Tomsk region, this indicator was unchanged in 1947 and 1948 – 1.5 ^{[31, L. 1-2]}; ^{[30, L. 5-6]}; ^{[6, L. 6]}; ^{[7, L. 8]}; ^{[23, L. 7]}.

Thus, the positive dynamics is obvious, but, as can be seen from the above statistics, it did not have the character of a long-term trend, because firstly, in the cities of Western Siberia, on the one hand, there was a rapid population growth, and on the other, there was still an outflow of doctors from the region, and secondlysecondly, in the conditions of the completed demobilization, medical universities and colleges were unable to prepare, and the distribution system to consolidate in the region the number of medical personnel that was necessary to occupy all available rates. Therefore, in 1948, the personnel shortage in medicine began to increase again: the ratio of doctors in Novosibirsk increased again to 1.5, the cities of the Novosibirsk region from 1.3 in 1948 to 1.4 in 1950. 70% of doctors worked there as part–timers, 58.9% of them had 1.5 rates, and 11% had more than two rates. Pediatricians of Kuzbass worked for more than two rates in 1948 ^{[31, l. 29]}; ^{[27, l. 15]}; ^{[8, l. 3]}.

It became obvious that an attempt to solve the problem exclusively by extensive methods gives only a temporary positive result, but does not lead to a stable correspondence between the needs of society in medical care and the possibilities of its provision. Since the organization of healthcare in the USSR was under the exclusive jurisdiction of the state, it was it that made an attempt to qualitatively change the industry, to find ways to make more rational use of existing material and human resources, while at the same time not abandoning the physical increase in the number of medical personnel.

In 1947-1953, the reform of the organization of urban health care was carried out. It assumed the rationalization of the use of the work of physicians and ensuring continuity in the treatment of patients. A fundamental innovation was the unification of hospitals and polyclinics into single medical institutions and the introduction of a two-link (hospital-outpatient clinic; hospital and home care) and a three-link (2 hours in the hospital, 3 hours at the site and 3 hours in the polyclinic department at the reception) system of work of physicians ^{[41, p. 165]}. The testing of the new system on the scale of the RSFSR showed that the second version of the working day regime did not give the results that were expected, especially with regard to narrow specialists. Even with an ideal organization, the doctor lost considerable time on the transition from one place of work to another and, accordingly, paid less attention to patients. This became especially evident in hospitals, where the time of bypass and examination of patients was often violated. Therefore, the three-link system of doctors' work within one working day was banned. Summing up the results of the introduction of a new system of medical care in April 1954, the order of the Minister of Health No. 69-m was issued "On measures to further improve the organizational forms of medical care and correct mistakes made when combining hospital and polyclinic institutions", which allowed doctors to work on a two-link system in cases where the hospital and polyclinic were located at a distance of no more than 1 km from each other. If these medical institutions did not correspond to each other in capacity or were further than 1-2 km from each other, then an alternating mode was introduced, when some of the district doctors served patients in the polyclinic and on the site, and the other in the hospital (in which each doctor had to work at least 3-4 months a year), then there was their replacement on a rolling schedule ^{[49, p. 24]}.

Table 2

The number of medical personnel in the cities of regions and territories of Western Siberia in 1946-1958. ^{[18, L. 68-74]}; ^{[18, L. 78]}; ^{[15, L. 139]}; ^{[15, L. 141]}; ^{[15, L. 143-146]}; ^{[15, L. 149-154]}; ^{[15, L. 157-158]}; ^{[16, l. 143-156]}; ^{[16, L. 167-168]}

Rationalization of the work of physicians in combination with quantitative replenishment of the number of medical personnel at the expense of young specialists should eventually solve the problem. However, obstacles also arose with the latter. The first of them was the introduction since 1946 of an extended 6-year period of study in medical universities instead of the accelerated completion of the program introduced during the war. An additional aggravating factor was the fact that some of the frontline doctors who arrived in the region after demobilization did not have the right to medical qualifications, because they did not have time to complete a full course of study before the war or passed it in an accelerated manner during wartime and therefore were forced to return to the student bench again. Only two years after the end of the war, by a joint order of the Minister of Higher Education and the Minister of Health of the USSR No. 630/277 dated May 7, 1948 "On the issuance of diplomas to persons prematurely released from medical institutes in wartime", it was decided to assign the qualification of a doctor to graduates of medical institutes at the end of 10 semesters during the war, if there is a positive characteristic from the last place works ^{[39, p. 16]}; ^{[39, p. 40]}. The second obstacle was the disproportion in the territorial location of medical universities that had developed in the pre-war period: out of 40 institutes of the Ministry of Health of the RSFSR, only 12 were located beyond the Urals. Of the six regions and territories of Western Siberia, only three had them: Omsk, Tomsk and Novosibirsk. Given the increasing role in the economic development of the eastern regions of the country, this imbalance had to be corrected, new educational institutions had to be opened in the territories experiencing the greatest shortage of personnel, while increasing the admission of students to existing specialized educational institutions. It was this approach that became dominant in the 1950s, although its practical implementation was not consistent. Since 1952, two medical institutes have been opened in Western Siberia in Barnaul and Kemerovo. By 1958, the number of students in the universities of the Trans-Urals increased by 44%, and in accordance with the Decree of the RSFSR No. 553 of August 10, 1956 "On improving the training of doctors and secondary medical workers in the regions of the Urals, Siberia and the Far East", the student intake contingent was brought to 5,900 people by reducing admission to medical institutes of the southern cities of the country. However, this did not exclude paradoxical situations with the distribution of young doctors. The Novosibirsk region, which has its own medical institute, annually graduating 350 specialists, and experiencing a chronic shortage of medical personnel, annually sent its graduates to other territories and regions of Siberia, the Far East, and Kazakhstan according to the order of the Ministry of Health of the RSFSR. At the same time, young specialists from specialized universities remote from Siberia regions were sent to the region. In 1948, 3 graduates of the Crimean Medical Institute, 5 – Kazan, 3 – Moscow were sent to the Novosibirsk region. Similarly, young doctors from the Crimea, Krasnodar, Saratov, Astrakhan, Leningrad were sent to the Kemerovo region, and in a much smaller volume graduates of Novosibirsk and Tomsk medical Institutes. Some of them "did not reach" the place of future work: out of 10 doctors – graduates of the Omsk Medical Institute sent to the Novosibirsk region in 1948, only 9 arrived, and out of 15 graduates of the Tomsk Medical Institute – 10. This situation was of a chronic nature and was reproduced throughout the period under review. Therefore, it was impossible to make up for the chronic shortage of personnel, and in 1956 600 medical positions remained vacant in the Novosibirsk region. This forced the local authorities to apply to the Central Committee of the CPSU with a request to leave 300 graduates of the Novosibirsk Medical Institute in the region, but the request was not granted ^{[19, l. 83-85]}; ^{[24, l. 39]}; ^{[26, l. 9]}; ^{[21, L. 39]}.

Despite all the difficulties, the increased attention of the state to the problem of personnel shortage in healthcare has nevertheless yielded positive results.  From the data in Table 2, it follows that the number of doctors in the cities of Western Siberia increased by 349% from 1946 to 1958, while the most significant growth took place in Kuzbass – 393% and Omsk region – 367%. Average growth rates were observed in the cities of Novosibirsk – 268%, Tyumen – 253% and Tomsk – 207% of the regions. The most unfavorable situation with medical personnel throughout the study period persisted in the cities of the Altai Territory, where their number increased by only 186% compared to 1947. But since the development of the healthcare system was determined by industrial and demographic growth, the main importance is not the figures of the mechanical increase of doctors, but the staffing ratios, part-time work and the number of doctors per 10 thousand urban population. In the USSR, the last indicator in 1955 was on average 17, in the RSFSR – 16.3, by 1960 in the USSR it reached 20, in the RSFSR – 19.3, and in urban settlements of the RSFSR in 1957 it was 21.3 ^{[50, p. 62]}; ^{[45, p.112]}; ^{[34, p. 620]}; ^{[40, p.139]}. In Western Siberia, the same indicator was lower: in 1950 – 13, in 1960 – 16 ^{[40, p. 139]}. Comparison of this coefficient in individual cities of the region shows that only the cities of two regions have approached the level of the RSFSR: Omsk and Tomsk. In the first in 1958 there were 19.1 doctors per 10 thousand population, in 1960 – 20, in the second in 1960 – 21.2. The remaining regions and edges could not achieve these indicators. In the Novosibirsk region in 1959, 16.7 doctors per 10,000 inhabitants, in 1960 – 17.6, in the Kemerovo region in 1957 – 9, in 1959 – 12.8, in 1960 – 13.8, in the Altai Territory in 1957 – 6, in 1959 - 8.5, in 1960. – 8,9 ^{[35, p. 109]}; ^{[48, p. 235]}; ^{[34, p. 534]}; ^{[19, l. 240]}; ^{[20, l. 96]}; ^{[1, l. 3]}. These figures show that the leader in the mechanical increase in the number of doctors – the Kemerovo region – was not such in terms of the provision of the population with them. This happened because the increase in the population in Kuzbass was ahead not only of the corresponding figures for all neighboring regions and territories, but even the average figures for the region: if in Western Siberia from 1939 to 1959 the number of inhabitants increased by 233%, then in Kuzbass – by 236%. Therefore, it is no coincidence that the staffing of medical institutions in Kuzbass by 1960 was only 60% of the need, and they often worked in 2.5 shifts. The cities of the Altai Territory, where the absolute increase in the number of doctors was the lowest in the region in the mid-1950s, also had a provision of about 60%.  Almost 100% of the staffing of urban medical institutions has been achieved in the Omsk and Tomsk regions, which corresponds to both a high indicator of their mechanical growth and a relative indicator of the provision of doctors for every 10 thousand residents. In Omsk in 1955 91% of full-time medical units were employed, in 1956 – 96%, in 1958 – 98%, in the cities of the Tomsk region in 1951 - 96.4%, in 1960 - 99%. However, the staffing of doctors by itself does not yet indicate a high quality of medical care, it is important that the part-time ratio remains low. Such a connection can be traced.  If in 1955 Omsk doctors worked on average at 1.9 rates, then in 1956 – at 1.4, and in 1958 – at 1.2. In the cities of the Altai Territory – the most problematic in terms of medical personnel provision, the replacement rate in the mid-1950s remained high and was equal to 1.5 ^{[9, L. 2]}; ^{[11, l. 39]}; ^{[47, p. 13]}; ^{[19, l. 240]}; ^{[29, l. 1]}; ^{[22, l. 21]}; ^{[22, L. 71]}.

Despite the fact that in absolute numbers the number of average medical workers was increasing, the problem of their provision of urban medical institutions in the region was no less acute than with the staffing of doctors. From the data in Table 2, it is obvious that, firstly, the increase in the number of nurses in the cities of the region as a whole was slower than the number of doctors. This feature can be traced throughout the entire period under review. Secondly, the dynamics of the increase in the number of nurses did not have a leading character from year to year. In particular, it stopped in 1948-1949, when the annual growth did not exceed 155%. Thirdly, there was a differentiation between the cities of the region. The fastest increase in the number of nurses was carried out in the cities of Kuzbass, amounting to 298% in 1946-1958, slower - in the cities of the Omsk region (221%). Indicators of other regions and territories were within these boundaries. As in the assessment of staffing by doctors in the situation with average medical personnel, the indicator of the number of average medical workers per 10 thousand inhabitants, presented in Table 1, is more informative. When comparing it, the disproportion between individual cities of the region becomes obvious. The most prosperous situation has developed in the cities of the Kemerovo region. In the cities of Kuzbass, this coefficient was 8.6 in 1950, 16 in 1955, and 18 in 1959. There were 7 medical schools in Kuzbass, which annually produce more than 500 nurses distributed to medical institutions in their region. Therefore, even in the post-war five-year period there was practically no shortage of average medical workers, characteristic of the rest of the regions of Western Siberia. By the end of the 1950s, the territorial areas of Novokuznetsk, Anzhero-Sudzhensk, Prokopyevsk, Leninsk-Kuznetsk were fully provided with nurses. However, this situation was not everywhere. In the cities of the Altai Territory in 1950, this coefficient was 7.1 nurses, in 1955 – 11.9, 1960 – 12.5, in urban settlements of the Omsk and Tyumen regions 5.3, 8.2, 8.9, and 4.2, 6.9, 7.2, respectively. It was most difficult in the Tomsk region, where there were only 3.0 average medical workers per 10,000 inhabitants in 1950, 4.3 in 1955, 4.7 in 1960, which represented the minimum indicators among all cities in the region ^{[10, L. 3]}; ^{[7, L. 16]}; ^{[5, L. 17]}; ^{[36, pp. 115-117]}.

This led to a high replacement index in lagging areas. In Omsk in 1946, a nurse worked at 1.4 rates, in Novosibirsk in the same year this coefficient was 1.9, in 1947 – 1.7, in 1948 – 1.6. There were not enough nurses for specialized types of care. Despite the fact that the Novosibirsk region had its own medical schools, in 1945, 1946, 1947, the number of paramedics-obstetricians in the regional center was 26, 7, 10, midwives – 45, 40, 42, respectively, while the number of obstetricians-gynecologists remained stable – 14. In 1949 in Novosibirsk 54 positions of the average medical staff remained unoccupied, in 1950 the number of vacancies almost doubled and reached 106, in the region – 500. In Tomsk in 1952, 64 doctors and twice as many nurses were missing – 129 ^{[30, l. 1]}; ^{[31, l. 1]}; ^{[12, l. 3]}; ^{[27, l. 17]}; ^{[25, l. 5]}; ^{[28, L. 3]}.

The quality of patient care largely depends on how many nurses there were per doctor. This indicator could not be high in conditions of chronic shortage of medical personnel, although some positive dynamics was observed. In the cities of the Tyumen region in 1946, it was 4.5, in 1947 – 4.6, in the cities of the Tomsk region in 1946 – 1.25, in 1947 – 1.44, of which 0.23 paramedics, 0.08 midwives, 0.94 nurses. By 1952, all therapeutic areas of Tomsk were staffed by doctors, but only 0.5 of the average medical worker's rate was assigned to each of them. In Novosibirsk in 1946, this indicator was 2.3. According to the health care structure of Novosibirsk that developed in the second half of the 1940s, there were an average of 5.8 positions of other medical workers for each medical position, in 1951 the City Health Department found it possible to increase the coefficient to 6.4, which, firstly, made it possible to staff medical sites with the necessary medical staff, although the load on it still remained large, since the number of the population at the sites still exceeded the standards. Secondly, to improve patient care ^{[7, L. 16]}; ^{[28, L. 13]}; ^{[30, L. 1]}.

An analysis of the situation within the industry in the post-war fifteenth anniversary allows us to conclude that all the measures taken during the three five-year period, including a large-scale reform of the reorganization of urban healthcare, testified to the obvious desire of the authorities to proportionally balance the number of medical institutions meeting modern requirements, qualified personnel, on the one hand, and the needs of citizens for medical care, on the other. The reform became a way to solve both problems by optimizing the use, first of all, of the potential that was already available. It gave positive results: if in 1940 none of the regions of Western Siberia came close to the Russian and allied industry indicators of the provision of the population with medical personnel, then by 1960 some of them reached this level. However, the total indicators for the region were more modest and indicated that, in general, the chronic backlog of urban healthcare in Western Siberia has not been eliminated, nor has the inter-regional inequality been leveled. The quantitative lag made the problem of improving the quality of medical care to citizens urgent, which would allow solving the main, from the point of view of the authorities, the task of healthcare – to provide industrial development of the region with labor resources.

Thus, in the post-war fifteenth anniversary, one of the most acute health problems in Western Siberia became personnel. It took place in relation to all levels of medical personnel of medical institutions. In the context of the active industrial development of the region and the increase in the urban population, attempts to optimize the organizational work of physicians made during the health care reform, the opening of new specialized educational institutions, measures to secure young professionals in the workplace still could not lead to overcoming the outflow and shortage of doctors and nurses. Incomplete staffing of full-time positions did not allow for the growth of the network of medical and preventive institutions in the cities of Western Siberia, and a large number of part-time jobs worsened both the quality and accessibility of all types of medical care for citizens.