Problems and contradictions of the development of the healthcare network of the Russian village during the "Khrushchev thaw": the second half of the 1950s — the first half of the 1960s (based on materials from the Saratov region)

Ischenko Yurii Vladimirovich PhD in History Associate Professor; Department of Public Health and Public Health; Saratov State Medical University named after V.I. Razumovsky 410017, Russia, Saratov region, Saratov, Novouzenskaya str., 63/65, sq. 63 ishenko1978@yandex.ru

Gumenyuk Aleksei Anatol'evich ORCID: 0000-0001-7024-2142 Doctor of History Professor; Department of National History and Historiography of the Institute of History and International Relations; Saratov National Research State University named after N.G. Chernyshevsky 410005, Russia, Saratov region, Saratov, Bolshaya Gornaya str., 267/269, sq. 60 gumenukaa@rambler.ru

In the context of the stated topic, many aspects of it have already been touched upon in a number of works in the Soviet and post-Soviet periods of Russian historiography ^[1-4]. At the same time, a number of them still remain outside the scope of historical research, or their coverage is somewhat superficial and fragmentary and does not form a holistic view of the development of healthcare institutions in the Russian countryside. For this reason, the reflection of the topic in the light of new historical knowledge and archival data remains relevant, which should contribute to a deeper study of the history of Russia, analysis of theoretical and practical problems of the domestic healthcare system.

It will be important to note that by the mid-1950s, taking into account the experience of previous periods and the conditions of agricultural production, the main forms of organization of medical care for the rural population and the nomenclature of appropriate medical and preventive institutions were developed. All this was supposed to solve the main dilemma of rural healthcare, which was identified back in the pre–revolutionary period - to increase the degree of accessibility of medical care to the population in conditions of low density, scattered settlements and production sites, lack of logistical and human resources, the expediency of their concentration and use in these circumstances (Regional State Institution "State Archive of the Saratov Region" (OSU GASO), F. R-2302, op. 5., d. 19, l. 5).

On the eve of Khrushchev's coming to power (1953) in the field of rural health, although the situation had improved compared to the period of the Great Patriotic War, nevertheless, there were many unresolved issues. As noted in the report on the work of medical institutions in the Saratov region for 1952, the financing of repair work and the construction of new medical institutions provided by the Ministry of Health of the RSFSR was extremely insufficient and could not meet the needs of the rural population in this direction ^{[5, p. 142]}.

The lack of medical personnel caused difficulties in deploying a rural medical network (OSU GASO, f. R-2302, op. 5., d. 19, l. 35).

By the early 1950s, among the main problems of rural medical institutions remained the lack of special equipment, materials, adapted premises, transport, etc. Despite the seemingly impressive growth of the medical network (1.4 times compared to 1940) ^{[6, p. 198]}, many rural medical institutions were housed in residential buildings private apartments and other adapted premises in need of major repairs that did not meet sanitary and hygienic requirements, were characterized by a small area and poor equipment with hard (furniture, dishes, medical instruments, etc.) and soft (bedding) inventory.

Neither the structure nor the staff capabilities created conditions for the rural medical area to provide specialized medical care, which, in general, had to be provided by district hospitals. Thanks to centralized sources of supply, they looked relatively well compared to the rest of the medical and preventive institutions of the Russian village. However, for example, in the Saratov region, only seven hospitals of this category had X-ray machines, a similar number of central district hospitals were not even electrified (OSU GASO, F. R-2302, op. 5., d. 19, l. 31-32).

In conditions of scattered settlements, lack of transport and off-road conditions, which complicated the possibility of timely hospitalization of women in labor in maternity hospitals, as well as the corresponding departments of district and district hospitals, the activities of collective farm maternity hospitals were important in bringing inpatient obstetric care to rural workers. Their importance was further emphasized by the fact that by the beginning of the study period, almost half of the workforce of the Russian village were women. At the same time, formally, collective farms were independent cooperative enterprises, which gave the state the opportunity to save on social expenses, including in the field of healthcare, shifting them to farms. At the same time, the consequence of the production and economic relations between the state and the collective farm-cooperative sector that developed in the previous period was the unequal withdrawal of resources from the latter. As a result, agricultural enterprises could not adequately build and maintain their health facilities. So, if according to the RSFSR, the number of maternity beds in medical hospitals in rural areas increased by 16% by the mid-1950s compared with the pre-war 1940, then the number of beds in collective farm maternity hospitals and at paramedic and obstetric stations by the early 1950s was about half the pre-war period ^{[1, p. 250]}.

Under the prevailing conditions, by the mid-1950s, about a quarter (26.6%) of the rural population of the country was served by outpatient clinics and 35.2% by inpatient institutions in cities ^{[1, p. 217]}. This phenomenon, in terms of servicing the rural population by highly specialized urban medical institutions, clinics of universities and research institutes, was rather positive. However, the solution of tasks related to the medical care of the rural population was also assigned to the hospitals of district cities and working settlements, the equipment of which left much to be desired (OSU GASO, F. R-2302, op. 5., d. 19, l. 41). This, in turn, although somewhat relieved the urgency of the issue, did not solve the main problem of approaching medical care in the Russian hinterland, called into question one of the ideological theses of Soviet healthcare about the accessibility and free medical care "for the entire population of the country" ^{[1, p. 214]}.

The modernization processes that began in the pre-war period formed new ideas about a "decent standard of living" in society. However, the measures taken by the party and state leadership aimed at the priority restoration of industry and cities led to the fact that the village became the main source of replenishment of their labor resources, and the development of agricultural production was not always accompanied by the creation of adequate social infrastructure. All this, together with the low financial interest of rural workers, contributed to the decline in the prestige of agricultural labor and migration of the rural population. The need for social and household improvement of the Russian countryside, including in the field of healthcare, became more and more obvious.

Serious changes in the agrarian policy of the state took place at the September plenum of the Central Committee of the CPSU (1953). It was recognized at a high level that agriculture would not be able to develop without qualitative improvement not only in the production, but also in the social sphere. If earlier even economically strong farms did not have the right to allocate significant funds for social and household needs, then the turning point was the decision to allow the latter to use part of their funds for the construction of maternity hospitals and other social infrastructure facilities ^{[7, p. 341]}. Along with a significant increase in purchase prices for collective farm products, the state decided to increase the sale of construction materials to collective farms, the lack of which sharply hindered the corresponding construction ^{[8, p. 165]}. Unprecedented resources were allocated by the state for socio-cultural construction in machine and tractor stations. At the same time, the construction of health facilities that unfolded in the mid-1950s, as well as the entire social infrastructure of the village, was complicated by a number of factors. In rural areas, there were practically no organizations capable of carrying out large amounts of construction work. Design organizations did not have time to provide construction organizations with technical documentation in a timely manner, without which it was impossible to finance them. For industrial ministries and departments involved by construction organizations, contracts for the construction of rural infrastructure facilities were unprofitable, they carried them out "from under the stick." Against the background of measures taken in the 1950s to decentralize economic management (reducing the set of planned indicators, weakening the role of regulatory authorities (Gosplan, Gossnab, etc.), ministries and departments used construction materials allocated from the all-Union fund primarily for the needs of their own enterprises, treating rural construction as a non-core, additional activity. In addition, national economic plans, providing for the allocation of construction materials for the amount of loans issued, did not take into account the developers' own funds, the size of which significantly exceeded the loans issued ^{[9, p. 163]}. As a result, the development of finance allocated for construction has become an extremely difficult problem. In a memorandum addressed to the first secretary of the Saratov Regional Committee of the CPSU, dated 1955, it was noted that the program for the construction of medical and children's institutions is not carried out annually, and the allocations allocated for these purposes are used within only 40-50% (Regional state Institution "State Archive of the Modern History of the Saratov Region" (OSU GANISO), f 594, op. 2., d. 3334, l. 149).

The creation by collective farms of their own enterprises for the production of bricks, tiles and other materials was prohibited in the early 1950s, since this activity was considered as distracting their attention from solving their main task. These unjustified restrictions, which were lifted only in the late 1950s, became one of the main reasons for the extremely slow construction of collective farm maternity hospitals, which directly brought medical care to the population of the Russian countryside. Thus, in the RSFSR, the number of maternity hospitals on collective farms increased from 1897 in 1950 to 2015 in 1958 ^{[10, pp. 335-336]}. In an effort to reverse this negative trend, in 1957 the Central Committee of the CPSU and the Council of Ministers of the USSR issued a joint resolution "On the development of housing construction in the USSR", which set the task of expanding collective farm construction, involving inter-collective farm construction organizations (MSO), to create enterprises for the production of building materials (Joint Venture USSR. 1957. No. 9. art. 102). The implementation of this directive and legislative act contributed to an increase in the production and supply of appropriate materials for the village, the expansion of the MSO network, the development of local industry that produced building materials from local raw materials, which gave some impetus to the development of a network of rural health facilities ^[11].

Despite the costs and contradictions of the process under study, by the end of the 1950s the number and capacity of rural district and district hospitals had increased. By this time, 984 paramedic and obstetric stations had been deployed in the Saratov region, with the forces and means of collective farms, state farms and about a hundred different facilities of medical and preventive institutions were built with budgetary funds, which were replenished with equipment, transport, hard and soft inventory ^[12]. However, as evidenced by numerous archival materials, by the end of the 1950s, neither the quantity nor the quality of the existing network of health facilities met the needs of the rural population. For example, in 74 state farms of the Saratov region there were no hospitals on central estates, 216 medical posts were missing (OSU GANISO, f. 594, op. 2., d. 4594, l. 29).

In the middle of 1958, a specially created commission began to develop the Third Program of the CPSU – a kind of plan for the construction of communism in the USSR for 1961-1980, adopted in 1961. One of the main tasks of the Program, according to the party and state leadership, was the elimination of imbalances between the standard of living of urban and rural populations, which, naturally, could not but affect on the further concept of rural healthcare development. The transformation of rural areas was focused on creating a model that would provide working and living conditions for villagers similar to urban ones. Overcoming the dispersed location of settlements was supposed to accelerate the reconstruction of the village. The enlargement of settlements made it possible to reduce the total cost of construction works and social infrastructure facilities ^{[13, p. 31]}.

In line with this concept, initiatives have been taken by the party and state leadership of the country in the field of healthcare. They aimed at the need to raise the medical care of villagers to the level that existed in cities. For this purpose, it was envisaged to expand the construction of enlarged rural hospital complexes with 100-120 or more beds (exclusively according to standard projects) both at the expense of collective farms' own funds and at the expense of state financing (Joint Venture USSR. 1960. No. 3. Article 14). At the same time, the construction of social facilities in the village was hampered by the unsatisfactory work of contractors and inter-farm construction organizations. The current planning procedure was also a serious problem, in which, instead of centralized supply of construction organizations, the supply of stock materials was assigned directly to farms. Many of them did not have workshops, or they were located in dilapidated and unsuitable premises, as a result of which they could not manufacture the appropriate equipment. Based on the priorities of economic development that had developed in previous periods, the bulk of building materials produced in the region and delivered from other regions were primarily used for the construction of industrial facilities, then agricultural production, and only last – the social infrastructure of the village ^{[11, p. 72]}.

The scrapping of the Stalinist planning system undertaken during the Khrushchev thaw, which was carried out specifically on physical indicators and objects, led to the fact that tasks began to be set in value terms and in general by industry. Such impersonal planning made it possible to "make a big maneuver" in the distribution and use of funds received from state and economic organizations by ministries and departments engaged in rural construction ^{[14, p. 456]}. The implementation of construction plans in the narrowly departmental interests of contractors was established based on the cost of construction and installation work done by them, and not on the commissioning of facilities. First of all, contractors sought to perform extensive work. There were cases when, in pursuit of appropriate indicators, they indefinitely stopped their activities at "launch" facilities and took on new, more profitable types of work from their point of view ^{[11, p. 72]}. As a result, the construction and, most importantly, the commissioning of rural health facilities lagged far behind the planned plans. So, in 1961, when implementing the plan for the construction of hospitals in the state farms of the Saratov region, only one hospital with 10 beds was commissioned by 50% (OSU GANISO, f. 594, op. 2, 4915, l. 185). "According to the pace of construction of hospitals in state farms, there is reason to assume that none of them, scheduled for completion by this year's plan, will be completed and put into operation" (OSU GANISO, f. 594, op. 2, d. 4914, l. 61), – it was noted in the certificate on the construction of medicalpreventive institutions in the Saratov region in 1962. A similar situation with the construction of health facilities was observed in collective farms. However, in the southern regions of the country with the presence of a large number of economically strong agricultural cartels, the scope of the construction of health facilities by the latter was impressive. In the Stavropol Territory, for example, in 1958-1964, 37 hospitals for more than a thousand beds, more than 50 maternity hospitals, 35 paramedic and obstetric stations, and five outpatient clinics were built at the expense of collective farms ^{[8, p. 204]}. Representatives of district organizations urged farm managers to adopt the Stavropol experience, however, due to objective and subjective factors, it was never implemented to the proper extent in Saratov collective farms (OSU GASO, F. R-1738, op. 3, d. 1353, l. 2).

As numerous archival materials show, in their decisions on the allocation of the limited resources available, the heads of farms and state organizations primarily proceeded from the interests of agricultural production. Funds were allocated to the social sphere that served him on a residual basis, their volume most often did not correspond to the development needs of the latter. For this reason, numerous requests from residents and even a number of representatives of party and Soviet organizations for the construction, repair and expansion of medical and preventive institutions, their equipment with transport, equipment, hard and soft inventory, provision of medicines, food, etc. did not always receive proper permission (OSU GASO, f. 1738, op. 3 174, l. 589).

In general, during the seven-year period, the number of rural hospitals in the Saratov region increased from 220 (together with dispensaries) with 4,058 beds in 1958 to 230 with 9,715 beds in 1964 ^{[15, p. 4]}. However, such a more than twofold increase in the number of beds in rural hospitals was achieved mainly due to the expansion and consolidation of existing medical institutions, as well as reorganization in connection with the consolidation of rural areas of the region in 1963 (there were 18 instead of 37 previously existing) of a number of urban hospitals into central rural hospitals (Balashovskaya, Pugachevskaya, etc.). By 1964, the average provision of beds for the rural population of the Saratov region was 4.9 beds per 1,000 people, while in the RSFSR as a whole, the same figure was six beds. It was he who was recognized as the norm for the rural precinct network. Due to the enlargement of some district hospitals, the boundaries of the activities of medical rural areas and paramedic-obstetric stations were expanded. At the same time, in conditions of priority construction and supply of large hospitals, only they had the opportunity to develop various forms of specialized medical care for the rural population. By the end of the study period, all central and zonal hospitals (former district hospitals that became part of enlarged districts), with an average bed capacity of 157 and 80 beds, respectively, were equipped with X-ray rooms, physiotherapy and clinical laboratories. However, only two of the 15 central hospitals were located in villages. If in 11 of them admission was carried out in all narrow specialties, there were electrocardiographic rooms, then in 4 receptions were organized only by urologists and traumatologists. Due to the lack of equipment and tools, dental care left much to be desired (OSU GASO, f. R-2302, op. 5, d. 206, l. 22; d. 212, l. 124-125). As the head of the Saratov regional health department Z.I. Morisson noted at one of the regional congresses of medical workers: "... in the last seven years (1959-1965), we have not yet solved (the issue) of creating the material and technical base of central district hospitals" ^{[16, p. 21]}.

As for district hospitals, in some cases, even where new buildings were built for them, due to numerous defects, they were still forced to be located in unsuitable premises (OSU GASO, f. 1738, op. 3, d. 1836, l. 4). In the Saratov region, by 1964, when The average provision of hospitals in this category was 24.1 beds in many of them there were not enough places, patients had to sit on chairs and in the corridors ^{[11, f. 2654, op. 24, d. 1, l. 48]}. Due to a shortage of beds, patients could be refused hospitalization, hospital stays were not respected and untreated patients were discharged ahead of time (OSU GASO, f. 1738, op. 3, d. 200, l. 41). In 97 hospitals out of 166 there were no X-ray rooms, in 75 – laboratories, in the 93rd – physiotherapy equipment ^{[4, p. 235]}. Due to the unsatisfactory power supply, even in those hospitals where new equipment was available, it was not always possible to use it, and operations were often carried out by the light of a kerosene lamp (OGU GANISO, f. 2654, op. 24, d. 1, l. 48). The organization of meals for patients and the supply of medicines to healthcare institutions were not always carried out at the proper level. About half a million residents of rural areas were not covered by ambulance and emergency medical care stations, which in such cases had to be provided by the forces of medical institutions serving the relevant area. However, in conditions of lack of transport and off-road conditions, the issue of organizing an emergency delivery of patients was not always positively resolved. Under the circumstances, about half of the patients who applied for medical care were served by medical staff, many of whom were housed in standard buildings, but a significant part of them were located in adapted premises belonging to rural councils and farms (OSU GASO, F. R-1738, op. 3, d. 1870, l. 3; F. R-2302, op. 5, d. 206, l. 119, 124).

The personnel problem significantly affected the functioning of the rural health network. In order to improve the provision of secondary medical workers to the village, the Saratov Regional Health Department decided to switch regional medical schools to train a contingent more in demand for the village – paramedics and midwives, by reducing the training of nurses, which since 1962 began to be conducted through the Red Cross. However, ill-conceived measures related, apparently, to the reform in the field of education (1958), as well as to the shortcomings of the material and technical base of educational institutions, led to a reduction in the corresponding category of graduates by more than 3 times - from 389 in 1960 to 116 in 1964 (OSU GASO, F. R-2302, op. 5, 212, 127). Almost a third of the doctors sent to the village were "involuntary" – they worked according to the distribution. Before they had worked for three years, for family and other reasons, they sought to leave for the city. Among the reasons for the turnover of medical workers in rural areas, it is necessary to include the fact that few rural youth entered medical schools, while the recruitment of medical universities and colleges in targeted areas from collective farms and state farms made it possible to assign permanent staff to them. However, the heads of farms were extremely reluctant to send their members to study at a medical university. So, in 1963, it was decided to send at least 30 people from rural areas of the region to study at the Saratov Medical Institute. However, only 11 people were accepted from collective farms and state farms in the directions (OSU GASO, f. R-2302, op. 5, d. 19, l. 125). As a result, if in 1964 there were 21.5 doctors per 10,000 citizens of the Saratov region, then in relation to the rural population the same indicator was only 8.1 ^{[4, p. 236]}. Due to the lack of medical personnel in rural areas, 323 medical and 780 positions of secondary health workers remained understaffed. The staff of 76% of rural district hospitals consisted of almost one doctor who provided medical care, not much different from a paramedic's, in the 41st hospital there was no senior medical staff at all. 111 (out of 1008) paramedic and obstetric stations were closed due to a shortage of average medical workers (OSU GASO, F. R-2302, op. 5, d. 206, l. 127).

Since the concept of resettlement from "unpromising" villages to urbanized settlements did not find support among the rural population, and the state, due to other economic and political priorities, did not allocate the necessary funds for its implementation, the structure of rural settlements continued to be fractional and dispersed. In some cases, enlarged villages were created not through the construction of new residential complexes, but through the administrative unification of small settlements. At the same time, small rural hospitals that were unprofitable from the point of view of the authorities could be closed, and the ongoing consolidation of hospitals did not always correspond to the size of the increased population included in their service area. If in the cities of the Saratov region by 1964 there were 8.4 hospital beds per thousand population (at a rate of 10), then in rural areas there were about five (at a rate of 6). However, these formal indicators, which were close to the norm, were superimposed by the fact that the bulk of beds were concentrated in large, mainly district and zonal hospitals, and the effectiveness of their use depended on solving many issues. In conditions of lack of transport and off-road conditions, especially during the spring and autumn thaw, residents of the Russian hinterland still had to travel tens and sometimes hundreds of kilometers to get qualified medical care, medicines, etc. to the nearest city or district center (OSU GASO, F. R-1738, op. 3, d. 357, l. 8; d. 698, l. 3; d. 1356, l. 1-2).

Thanks to the measures taken by the leadership of the Soviet Union, during the period under study, it was possible to improve a number of indicators for the development of rural health care. For example, from 1958 to 1962, the incidence of acute gastrointestinal diseases in the rural population of the Saratov region decreased from 13 to 7.7 per 1,000 people, the cardiovascular system from 14.7 to 5.2 people, and the total incidence from 400 people in 1960 to 383 people in 1962, respectively. Coverage of rural workers with inpatient maternity care increased from 65.3% in 1958 to 85% in 1962 (OSU GASO, F. R-2302, op. 5, 212, l. 128). At the same time, the question remains to what extent the improvement of these and other indicators was due to the development of the rural health network, and to what extent – to an increase in the material and cultural level of the population, the development of the general infrastructure of the village. But this is a separate topic that is still waiting for its thoughtful researcher.

Thus, as historical analysis shows, during the period under study, the leadership of the USSR took measures to build and develop a network of rural medical institutions in order to eliminate disparities between the level of medical care for urban and rural populations. As a result, it was possible to achieve certain improvements in a number of quantitative indicators of rural health care, which was reflected in an increase in the number of hospital beds in the rural health network, and a decrease in the disease of the corresponding category of the population. At the same time, ill-conceived economic transformations in the field of planning led to the fact that the construction of health facilities in a Russian village did not cover the needs of its residents. The formal increase in the number of beds through the expansion and consolidation of existing premises in rural hospitals rather reduced the quality of medical care. The concentration of resources of the rural health network in the central hospitals of enlarged areas in conditions of fragmentation of rural settlements, lack of transport, off-road and other unresolved problems of rural infrastructure led to the fact that highly qualified specialized medical care by the end of the study period remained inaccessible to the bulk of the population of the Russian countryside. And although a lot has been done to develop paramedic and obstetric care for the rural population, however, the activities of the relevant points were hampered by a lack of medical personnel and adapted facilities. For this and other reasons, the issue of bringing medical care to the rural population to the end of the period indicated by the chronological framework remained largely unresolved. As evidenced by the analysis of the practical experience of the measures taken, attempts to solve the problems of the rural health network mainly through administration could not compensate for the shortcomings of the development of the relevant infrastructure. Their effectiveness largely depended on the comprehensive solution of problems related not only to the development of the material base, personnel and financing of health facilities, but also the general infrastructure of the village.