G. E. Rein's Healthcare Reform Project: Missed Opportunities for Modernization of the Russian Empire 1906-1917.

Tarabara Dmitry Olegovich Postgraduate, Department of Theory and History of Law, Saint-Petersburg State University 199034, Russia, Saint Petersburg, Saint Petersburg, Universitetskaya Embankment str., 7/9 tarabara@list.ru

1. Introduction. In the late XIX – early XX centuries, the healthcare system remained on the "periphery" of Russian modernization – it has not undergone significant changes almost since the Great Reforms, unlike, for example, the education or social security system. Nevertheless, an objective assessment of the trends and prospects for the development of this sphere in the last pre-revolutionary decade is impossible without investigating numerous attempts to reform it and, accordingly, the reasons for their failure. This article presents an analysis of the most ambitious and promising project for the reform of medical and sanitary legislation, developed by the central government in the first half of the 1910s, in terms of its ability to solve the main problems of domestic healthcare in the period under review.

In world history, the turn of the XIX–XX centuries was marked, on the one hand, by numerous scientific discoveries that changed ideas about the origin of diseases, the possibilities of their prevention, diagnosis and therapy, and, on the other, by the rapid expansion of state intervention in the field of healthcare under the slogans of creating social medicine ^{[23, pp. 646-647; 30, p. 104, 110]}. The Russian Empire cannot be called an exception to these trends, however, by the beginning of the twentieth century. the development of the domestic healthcare system was hampered by a whole range of serious problems: general weakness and departmental fragmentation in the field of management, archaic medical and especially sanitary legislation, low public spending on healthcare and, as a result, low provision of the population with medical personnel and medical infrastructure.

The need for large-scale transformations in the healthcare sector was realized by the central government in the second half of the XIX century. At the same time, the direction of reform was determined, which became the key for all commissions for the revision of medical and sanitary legislation for decades to come - the centralization of health management and the creation of a special executive body authorized in this area. However, the reformers invariably faced opposition, firstly, from individual ministries who did not want to give up their powers, and secondly, from representatives of the zemstvo and city medicine, who zealously defended their autonomy from external encroachments. The complexity and multidimensionality of the healthcare system has made it a collision field of numerous political interests.

As a result, the body of bills aimed at the comprehensive modernization of the healthcare system was prepared only by the mid-1910s. The absolute majority of them were developed by the central government solely on its own initiative: part by the Ministry of Internal Affairs under the Office of the Chief Medical Inspector, part by the Interdepartmental Commission for the Revision of Medical and Sanitary Legislation under the leadership of the Chairman of the Medical Council, academician G. E. Reina (1854-1942).

The analysis of the projected reform is complicated by the fact that these bills at the beginning of 1917 were at different stages of development, adoption and approval: some somehow received the Highest approval, others were under consideration by the Council of Ministers or the State Duma, others were not even worked out by their authors in the final version. However, this circumstance has a downside, allowing for a better understanding of the views of different participants in the legislative process on the projected reforms and the specifics of interaction between them.

2. The Healthcare Management Transformation Project. At the beginning of the twentieth century, the management of civil medicine in the Russian Empire was the responsibility of the Ministry of Internal Affairs. The Medical Council formed in its composition was recognized as the "highest medical and scientific institution for the consideration of issues of public health protection, healing and forensic medical examination", which received all draft laws and government orders on the medical and sanitary part. Despite such a high status, this body was advisory and could not effectively influence health policy ^{[29, pp. 1-2]}.

Directly managerial powers after 1904 were distributed between the Office of the Chief Medical Inspector, as well as the Council for Local Economy and the Main Directorate for Local Economy, which were also part of the structure of the Ministry of Internal Affairs. With a certain degree of simplification, it can be said that the competence of the first included control, supervisory and personnel powers in the field of healthcare, as well as the management of measures to combat epidemics, the competence of the second and third - economic powers in the field of providing medical care to the population, taking sanitary measures and running medical institutions subordinate to the Ministry of Internal Affairs ^{[29, c 6-7, 10-11]}.

The management of health care in the provinces and regions was carried out by Medical departments (departments, boards), which are part of the provincial boards. Despite their formal subordination to the Office of the Chief Medical Inspector, these bodies did not have the opportunity to influence health policy in the region – their role was limited to fulfilling the orders of Governors and provincial boards ^{[29, p. 17]}. The lower management level consisted of county and city doctors who suffered from an excess of responsibilities – their competence included not only sanitary supervision and epidemic control, but also the implementation of forensic medical research. In practice, the execution of the last of them was carried out to the detriment of the rest, which could not but affect the quality of management ^{[14, p. 184-185]}. The situation was aggravated by a personnel shortage – the law, as a general rule, provided for only one position of a county doctor per county.

At the same time, the top management of the medical unit in the regions of the Don, Tersk and Kuban troops, as well as in the Turkestan General Government, was entrusted to the Ministry of War. Separate control powers in the field of healthcare remained within the competence of other departments: for example, the Ministry of Railways carried out sanitary supervision on railways and inland waterways, the Ministry of Trade and Industry – in factories and plants within the scope of work, etc. ^{[24, pp. 183-187]} In addition, almost every ministry had its own medical- the sanitary part, as a result of which the organization of medical care in the army and navy, in the Cossack troops, in the cities of the palace department, on the railways, in places of resettlement, in educational institutions, in commercial ports, at state-owned mining plants and mines, in places of detention, etc. was actually removed from direct supervision The Ministry of Internal Affairs.

Finally, it should be especially emphasized that most of the work directly on providing medical care to the population and preventing diseases was carried out not by state authorities, but by local governments, which traditionally enjoyed wide autonomy in this area ^{[22, p. 26]}. About 50% of the Russian Empire's bed stock was concentrated in zemstvo and city hospitals, and local budget expenditures on the medical and sanitary part significantly exceeded the state ones both in absolute and relative terms.

The solution to the problems of weakness, fragmentation and haphazard work of management structures was to be the establishment of a new executive authority – the Main Directorate of Public Health, with a three–level system of territorial bodies - in counties, provinces and projected medical and sanitary districts – located in vertical, strictly hierarchical subordination. The governors continued to exercise general control over the activities of local health authorities, but were completely deprived of legal mechanisms to influence their decision-making and execution of management decisions. The functions of administrative and forensic medical examinations, research and examinations were supposed to be transferred to forensic doctors specially created for these purposes ^{[26, p. 445]}. The staff of the new body was noticeably expanded – the Main Directorate alone should have included more than 90 employees (for comparison, the staff of the Office of the Chief Medical Inspector consisted of only 14 people ^{[29, p. 9]}).

It is important to note that the draft law of the G. E. Rein Commission did not provide for strict centralization of health management, requiring the breakdown of institutions that had developed by the beginning of the twentieth century. The achievement of the planned development of healthcare and the coordination of the activities of all state and public institutions in the views of the reformers should not have been accompanied by either the deprivation of local governments of a certain independence at the disposal of the sanitary and medical part, or the reassignment of departmental medical and sanitary institutions and medical personnel to the new Main Directorate ^{[14, pp. 49-50]}.

The compromise nature of the reform was most clearly manifested in the design of special "uniting and conciliatory" bodies: county and provincial medical and sanitary councils, as well as district medical and sanitary meetings - designed to coordinate the activities of local government and municipal bodies "both during the existence of epidemics and in their free time from epidemics." They were to include doctors, representatives of all interested departments, local governments and estates. Contrary to the thesis about the "predominance of the bureaucratic and class element over the public" ^{[22, p. 214]}, representatives from local governments and zemstvo doctors made up the majority in the county medical and sanitary councils, and about half of the composition in the provincial ones.

Directly in the system of the Main Directorate of Public Health, it was planned to create a special coordinating body – the Main Sanitary Council, designed to ensure "the closest connection between the Main Directorate of Public Health and zemstvo institutions and city public administrations, as well as government, public and private institutions that care about the protection of public health." The competence of the Council included:

• discussion of legislative assumptions and measures on the medical and sanitary part concerning the interests of government and at the same time zemstvo institutions and city public administrations;
• consideration of applications and petitions of zemstvo institutions and city public administrations for changes in medical and sanitary laws and regulations;
• consideration of applications and petitions for the issuance of benefits from the treasury to meet local sanitary and medical needs.

According to the original plan of the G. E. Rein Commission, the Council should have included both employees of the concerned executive authorities and representatives from each province, as well as from each city allocated to an independent zemstvo unit or enjoying the right of separate elections to the State Duma. Representatives from zemstvo provinces were elected by provincial zemstvo assemblies, from cities – by city dumas for a period of one year ^{[27, p. 2-3]}. In fact, a draft was proposed for one of the first institutions in the history of national public administration based on the principle of universal territorial representation.

Nevertheless, at the stage of consideration of the draft law by the Council of Ministers, the specified formation procedure was considered irrational. The territorial representation was reduced threefold: one representative each from three zemstvo provinces, three "non-zemstvo" provinces and three of the above-mentioned cities ^{[14, pp. 93, 145-146]}. The rotation of provinces and cities was determined by the Governor-in-Chief, however, due to the inevitable artificiality of any order proposed by him, he was given the right to invite representatives from provinces and cities to meetings of the Main Sanitary Council in excess of the established number.

Finally, it was proposed to make changes to the composition of the Medical Council – one representative from the city and from the zemstvo public institutions was introduced into it as permanent members. They were supposed to be elected for a term of one year from among the representatives of the zemstvos and cities that make up the Main Sanitary Council.

In modern historiography devoted to the projected reform, the point of view has spread that the reformers proposed to create "a complex hierarchical health management system that suppresses local initiative and strictly regulates the forms and methods of medical care" ^{[8, p. 55]}. This statement can hardly be considered true. It contains an unreasonably simplified view of both the projected transformations and the political processes in the late Russian Empire.

Of course, the establishment of a special executive authority could not but lead to the centralization of health management. At the same time, neither the provisions of the relevant draft law nor the materials of the G. E. Rein Commission indicate the desire of reformers to destroy the existing system of interaction between the state and local governments, much less destroy public medicine.

On the contrary, the authors of the bill purposefully provided the zemstvo and city self-government bodies with an institutionalized subjectivity in the field of public health management. It is possible to discuss what the degree of their influence on the development of managerial decisions would actually be, but it must be admitted that over the previous fifty years of the existence of public medicine, they basically did not have such an opportunity.

In the context of the arguments about the "suppression of local initiative", it is appropriate to mention one more circumstance. According to the original plan of the reformers, the territory of the Empire was supposed to be divided into twelve medical and sanitary districts with the establishment in each of them of a District Medical and Sanitary Department - a purely bureaucratic body designed to direct the activities of Provincial Medical and Sanitary Departments ^{[27, pp. 11-12]}. The Council of Ministers, in turn, considered the district level of health management unnecessary – the final version of the bill envisaged the creation of district administrations only in the Amur, Irkutsk and Turkestan governorates general, as well as in the Caucasus ^{[14, p. 101]}. It is easy to see that none of the listed districts had zemstvo provinces – zemstvo medicine was completely removed from additional government control.

It should be noted that although the medical community perceived the idea of establishing the General Directorate of Public Health rather in a negative way ^{[2, pp. 38-39]}, otherwise its ideas about the modernization of the health care system, as a rule, coincided with the proposals of the central government.

3. Modernization of medical and sanitary legislation. Thus, in the fight against infectious diseases, both reformers and zemstvo doctors proceeded from the priority of sanitary measures and improvement of living conditions over quarantine measures, which resulted in the development of a whole package of bills that fixed sanitary and epidemiological requirements for residential premises, domestic water supply, waste management, clean air, food, household items household items, burial sites, medical areas, etc. Some of the projects involved a radical revision and updating of the provisions of current legislation, some – the regulation of relations that previously remained outside the legal field, and the creation of fundamentally new institutions.

Numerous discoveries in the field of bacteriology, epidemiology and social hygiene have provided a scientifically sound approach to legal regulation. Practically each of the "sanitary" bills assumed the publication on its basis of special by-laws regulating such "technical" issues as the norms of the content of organic and inorganic substances in tap water, the norms of permissible pollution of atmospheric air with smoke, methods and means of disinfection of things and premises, lists of substances allowed and prohibited in the manufacture of one or another products , etc.

The quality of the projected sanitary legislation was also positively affected by the fact that during its development, reformers could much more freely receive advanced provisions of foreign legislation – the uniqueness of the domestic health care system was manifested in this area much less than, for example, in the organization of medical care to the population. As a result, some of the draft laws developed, for example, the Regulation on Measures to Prevent and Control Infectious Diseases and the Regulation on Sanitary Protection of Homes, largely complied with the standards of medical legislation of Great Britain, France, the German Empire and other foreign countries.

Imposing on the state the responsibility for health education of the population promised to have large-scale consequences. In the pre-revolutionary period, medical knowledge was popularized primarily by medical, scientific and educational public associations, as well as individual zemstvos on their own initiative. The bill also provided for the publication of popular books, pamphlets, leaflets and posters at the expense of the treasury, as well as the provision of grants to zemstvos, cities and public organizations for educational activities; a large-scale task was proclaimed to introduce the basics of healthcare in primary schools and parish schools, and hygiene in secondary educational institutions ^{[26, p. 265-267]}.

It should be noted that the reformers recognized the importance of adapting general sanitary regulations to local conditions, and in the vast majority of cases did not infringe on the right of zemstvo assemblies and city councils to issue mandatory regulations in the field of sanitary supervision. The procedural issues of its implementation also had to be regulated primarily by local regulations.

The analysis of the developed draft laws allows us to identify four models of legal regulation of certain issues in the field of sanitary legislation:

• exclusively mandatory resolutions of local self-government bodies;
• general provisions of the law and mandatory resolutions of local self-government bodies adopted in addition to them;
• general provisions of the law, by-laws of executive authorities and mandatory resolutions of local governments adopted in addition to the latter;
• exclusively by law and (or) by-laws of executive authorities.

Most bills, as a rule, combined several of the above models. Thus, in the draft Regulations on Sanitary Protection of Air from Smoke Pollution and Regulations on sanitary requirements, which must be met by premises and places of sale and manufacture of food and beverages, the first model of legal regulation prevailed, in the draft Regulations on Sanitary Protection of Water, Air and Soil and Regulations on Sanitary Protection of Dwellings – the second and fourth, in the draft Regulations on ensuring the quality of food and flavoring products and Beverages are the third, the draft Regulations on Measures to Prevent and Control Infectious Diseases are the third and fourth, the draft Regulations on the Construction of Cemeteries and crematoriums, on burial and Registration of the dead are the first and fourth. An exception to the general background was the draft Regulation on ensuring the harmlessness to health of certain household items, the norms of which completely excluded municipal law-making ^{[13, p. 9]}.

The reformers recognized the autonomy of zemstvos and cities not only in rule-making, but also in executive and administrative activities. The late Russian Empire knew an example of a healthcare reform that failed due to excessive regulation of zemstvo medicine and ignoring local peculiarities – we are talking about an attempt to adopt the Charter of medical institutions of the Ministry of Internal Affairs in 1893, the validity of which was suspended two years later at the numerous petitions of zemstvo self-government bodies ^{[11, p. 16-20]}. The members of the G. E. Rein Commission were fully aware of the reasons for the failure of their predecessors and tried to prevent the repetition of their mistakes.

None of the draft laws provided for the reassignment of municipal medical institutions to the General Directorate of Public Health, much less their nationalization. Local self-government bodies retained the right to establish, open and close medical institutions by turnout, manage and manage them on the basis of general laws, as well as their own rules and instructions, freely invite and dismiss staff ^{[26, pp. 299, 303, 311]}.

The versions of the bills that have come down to us did not fix the general provision on free medical care for the population (with the exception of patients with acute infectious diseases, syphilis, fracture and trachoma) – the amount of payment and the conditions for exemption from it were established by mandatory resolutions of departments or local governments, at the expense of which medical institutions were maintained ^{[26, p. 309, 313-314]}.

The Commission of G. E. Rein did not prevent the existence of a wide range of practices of inter-municipal cooperation in the field of healthcare, on the contrary, from now on, the possibility of transferring powers for medical and sanitary measures from a city with a population of less than 20 thousand people to a county zemstvo and from a county zemstvo to a provincial one on the basis of agreements between them was explicitly provided for ^{[26, p. 98]}.

It is interesting to note that in cases where the authors of the bills nevertheless turned to mandatory norms in regulating the activities of zemstvos and cities, this often represented an attempt to legislate positive practices already existing locally and, accordingly, scale them to the entire territory of the Empire - an example of this is the norms on providing medical care at home, on unity of command in the management of medical institutions and on mandatory medical duties ^{[26, pp. 301, 304, 315]}.

Even the most controversial requirement for the mandatory creation of special bodies for the management of the sanitary and medical part and advisory medical and sanitary meetings at the zemstvo and city councils, which can indeed be considered as an unjustified encroachment on the independence of local governments, was not divorced from the practice of public medicine ^{[26, pp. 98-99]}.

In this prescription, one can easily see an attempt to legalize the zemstvo and city sanitary bureaus, medical and sanitary councils and other collegial bodies under the administrations that have existed for several decades. In this regard, it is appropriate to quote the following: "It would be impossible not to welcome such a legislative act by which the sanitary councils recognized by the majority of zemstvos would be established as a permanent and universal institution under the zemstvo councils. This, as we are deeply convinced, would have leveled the entire medical and sanitary business in Zemstvo Russia at once" ^{[15, p. 178]}.

4. Providing affordable health care: plans and reality. Of particular importance in the modernization of the healthcare system was the consolidation of minimum quantitative requirements for the provision of medical and sanitary infrastructure and medical personnel. Taking into account the fact that these prescriptions were uniform for all regions, their implementation would allow, firstly, to complete the unification of the system of medical care to the population of the Russian Empire (by 1914, the rural medical unit based on the precinct system had not been introduced in the Ostzey and Privislinsky provinces, with the exception of Estland and Plock), secondly, to smooth out the disproportions of the territorial development of its individual parts.

At the same time, it was obvious that the legislative consolidation of unreasonably high, obviously unfulfillable requirements threatened to discredit the reform and turn into its complete failure. Probably for this reason, a rather cautious approach was chosen, which, as a rule, establishes a scientifically or logically justified minimum of requirements. Reformers and public medicine figures also demonstrated a consensus in absentia on this issue.

The most significant in this regard are the prescriptions of the Regulation on providing public medical care to the population, according to which the main unit of medical care was recognized as a medical area with a radius of no more than 10 versts and a population of 9 to 11 thousand people. This requirement applied to areas with a population density of 29 to 35 inhabitants per square mile – with a higher or lower population density, deviations from these parameters were allowed ^{[26, pp. 315-316]}. In each medical area there was to be a medical institution with permanent beds for therapeutic and surgical patients and with special departments for acute infectious diseases and women in labor. The absence in this bill, as well as in all others, of references to independent paramedic stations gives reason to believe that the G. E. Rein Commission intended to solve the problem of "paramedicism", condemned by zemstvo doctors since the end of the XIX century.  

The above fragment of the draft law reproduces almost verbatim the description of the proper arrangement of medical sites from the fundamental work of Z. G. Frenkel "Essays of the zemstvo medical and sanitary business", where the following parameters were scientifically substantiated: radius - no more than 10 versts, area – no more than 314 sq. v., rural population – no more than 10 thousand people. In each section, it was supposed to organize a hospital with the following departments: an outpatient clinic, a hospital proper, a syphilitic department, an infectious barracks, a maternity ward ^{[28, pp. 92, 110, 112]}.

The requirements for the minimum equipment of medical sites and settlements with general and special beds are presented in the following table.

Table 1. Requirements designed by the G. E. Rein Commission for the minimum equipment of medical sites and settlements with a bed fund ^{[26, pp. 316-317]}

Surprisingly modest requirements were fixed in the draft Regulations on the protection of Motherhood, Infancy and Childhood. They provided for the creation of nurseries providing at least 5% (in counties) and 2% (in cities) of the total available child population under the age of 5, as well as children's consultations at the rate of at least one per 20,000 inhabitants (for cities with a population of 20 to 200 thousand people) or 50,000 residents (for cities with a population of over 200 thousand people). In addition, in cities, children's consultations were necessarily established at children's hospitals, children's departments of hospitals, orphanages, educational shelters and maternity shelters; in rural areas, only optional consultations were provided at zemstvo hospitals ^{[26, pp. 112-114]}.

The draft laws provided for the creation of a more complex medical infrastructure. So, in every province, county and city with a population of over 50,000 people, disinfection services were to be set up, as well as laboratories for the production of bacteriological and sanitary research ^{[26, pp. 101, 103]}. In addition, local governments were instructed to ensure the possibility of laboratory research of food and flavoring products and beverages in all settlements with a population of over 25 thousand people ^{[26, pp. 223-224]}. In settlements with a population of over 25 thousand people, the mandatory installation of public water supply was provided, and with a population of over 40 thousand people, sewerage was also provided ^{[26, pp. 176, 178]}.

Regarding the provision of medical personnel to the population, it was prescribed that for one normal medical site in rural areas and for every 11 thousand people in cities there should be at least one doctor and three persons of junior medical staff ^{[26, pp. 315-316]}. In addition, the county zemstvos were obliged to maintain at least one sanitary doctor per county, and the city councils of cities with a population of over 20 thousand people – at least one sanitary doctor per city (for cities with a population of over 50 thousand people – for every 50 thousand inhabitants) ^{[26, p. 99]}. It is worth noting that only such a number of sanitary doctors allowed for at least minimal supervision of compliance with mandatory regulations of provincial zemstvos ^{[9, p. 71]}. In addition, in cities with a population of over 25 thousand people, it was supposed to establish special posts of housing and sanitary inspectors, the number of which was to be determined by city councils.

Nevertheless, the development indicators achieved by the domestic healthcare system before the First World War lagged significantly even from these minimum requirements ^{[25, p. 7, 17, 18]}.

Thus, the number of medical sites in the Empire turned out to be three times less than the projected one; even in the 34 most developed "Starozem" provinces, their number needed to be more than doubled. In no province of Russia has the full compliance of medical sites with the optimal criteria of radius, area and population in the aggregate been achieved ^{[21, p. 58]}. Separately, it should be noted that despite the constant increase in zemstvo health care costs, the average growth rate of the number of medical sites in these provinces has shown a downward trend over time.

Table 2. Indicators of the dynamics of the development of the network of medical sites in the "Starozem" provinces ^{[28, p. 121; 19, p. 57; 21, p. 89]}

The total number of hospital beds in the Empire (including beds in factory, private and departmental medical institutions) turned out to be 3.3 times less than projected. The average growth rate of the bed stock in "somatic" hospitals both in 1903-1908 and in 1908-1913 was at the level of only 1,042 ^{[20, pp. 66, 67, 71; 21, pp. 60, 61, 64]}. The number of beds in psychiatric institutions was 43% of the minimum standard, the number of beds for women in labor was only 8.7% ^{[21, p. 61, 64]}. In 1910 24% of the sites in 34 "Starozem" provinces did not have hospitals – the same figure was recorded in 1870 ^{[28, p. 121]}.

According to Z. G. Frenkel's data, which probably requires some adjustment, at the beginning of 1913 only 13 out of 40 zemstvo provinces (excluding Astrakhan, Orenburg and Stavropol) satisfied the requirement of one sanitary doctor per county ^{[28, pp. 202-203]}. Things were a little better in the cities. D. N. Zhbankov's research showed that in 1913, only 6 out of 33 cities with a population of over 100,000 people and 12 out of 54 cities with a population of 50 to 100 thousand people met the requirements of the draft laws for the number of sanitary doctors. If we include among the sanitary doctors the heads of the sanitary bureau, school, epidemic, trade and sanitary doctors, as well as employees at laboratories, disinfection chambers, etc., the figures will increase to 22 and 24 cities, respectively. Sanitary organization in cities with a smaller population, as a rule, was much weaker, and sometimes completely absent ^{[10, pp. 442-449]}.

In 1913, there were only 61 hygienic laboratories operating throughout the Empire for the study of food and flavoring substances, of which 49 were maintained by cities, 2 by zemstvos, 1 jointly by the zemstvo and the city ^{[21, p. 67]}. Disinfection chambers and laboratories for the production of bacteriological and sanitary research were also not widespread.

According to the Office of the Chief Medical Inspector, on January 1, 1911, there were 197 settlements with a population of over 25 thousand people and 111 with a population of over 40 thousand throughout the Empire. Of this number, only 107 were equipped with water supply and only 9 with floating sewerage ^{[12, L. 47; 1, p. 15]}. In total, there were 227 public water pipes in 204 settlements in the country. The water quality in them is eloquently evidenced by the fact that only 59 water pipes (26%) were equipped with filters, and constant sanitary supervision of water quality was organized in only 65 settlements (32%) ^{[1, p. 11, 13]}.

The next six years of urbanization and the progressive development of urban utilities have somewhat changed the situation for the better. So, from 1912 to 1917, water pipelines were put into operation, for example, in Omsk, Krasnoyarsk, Ryazan, Cherkassy, floating sewerage – in Kharkov, Samara, Saratov, Tsaritsyn, Perm. Nevertheless, most of the pre-revolutionary cities continued to be in a state of sanitary distress.

5. Financial and legal aspects of the reform. While maintaining the pace of development of the healthcare system observed in 1900-1913, the achievement of the standards developed by the G. E. Rein Commission would have stretched for more than two decades. With such a significant discrepancy between the projected requirements and reality, the modernization tasks could not have been achieved without a significant increase in public spending on this area. According to preliminary estimates, the costs of organizing public medical care should have amounted to at least 648 million rubles of one–time expenses and 387 million rubles annually ^{[25, p. 19]}, for the installation of water pipes and sewers - at least 200 million rubles ^{[4, l. 122]}.

Thus, the financial component of the reform became almost the most important part of it. In this issue, the reformers proceeded from the preservation of the status quo in the sense that most of the health care costs should be financed from the funds of the city and provincial budgets. Thus, the need to reform the healthcare system turned out to be inextricably linked with solving the problem of insufficient revenues of local budgets. The G. E. Rein Commission proposed to solve it in two ways: securing a new source of income for local budgets in the form of a special fee for medical and sanitary needs (probably by analogy with the hospital fee levied in sixteen cities) and providing them with transfers from the state budget ^{[26, p. 322]}.

However, the reformers did not immediately realize the problem. An analysis of the draft laws under study shows that earlier ones, especially those developed by the Ministry of Internal Affairs under the Office of the Chief Medical Inspector, did not provide for financial support measures for local budgets even in such global issues as the installation of water supply and sewerage. In this regard, the positive role of the State Duma should be particularly noted – it was on its initiative that the draft Regulation on ensuring the quality of food and flavoring products and beverages was supplemented with a norm on reimbursement of half of the costs of setting up and maintaining zemstvo and city laboratories, and the draft Regulation on sanitary protection of water, Air and soil – on subsidizing half of the costs for sanitary measures that do not generate income, and the issuance of interest-free loans to cities for the construction of water supply and sewerage.

For a better understanding of the context in which the proposals of the G. E. Rein Commission were developed, it seems appropriate to elaborate on the characteristics of inter-budgetary relations in the Russian Empire.

The first cases of state subsidization of local health care costs took place in the second half of the 19th century, however, both in terms of volume and frequency of provision remained an extremely inconspicuous phenomenon until the early 1910s. Until that time, allowances from the treasury, in principle, did not play a significant role in the revenues of local budgets – suffice it to say that they accounted for only 1.9% of the revenues of zemstvos in 1900-1902 ^{[6, p. 38]} and 0.37% of the revenues of cities where Municipal Regulation was introduced in 1899-1901 ^{[16, p. 64-65; 17, pp. 64-65; 18, pp. 64-65]}. The situation began to change only in 1908 with the allocation of 6.9 million rubles from the treasury as allowances to local governments for measures to introduce universal primary education. Gradually, subsidizing local budgets was extended to other areas as well – as a result, in 1912, benefits from the treasury already amounted to 13.6% of the revenues of the zemstvo budgets and 6.5% of the revenues of the budgets of cities where Urban Regulation was introduced ^{[5, p. 37; 7, p. 41]}.

As for health care costs, since 1911, a number of model laws have been adopted annually providing for the allocation of allowances to city and provincial institutions for the implementation of anti-plague and anti-cholera measures:

• for the hiring of additional higher and lower medical personnel, for the costs of purchasing medicines, disinfectants and instruments;
• to improve water supply sources;
• for the construction of temporary medical institutions (barracks, hospital outpatient clinics, etc.) and medical and nutritional points.

Initially, it was supposed to reimburse local governments for half of the amounts allocated for these purposes, but already in 1913 an increased amount of transfers was introduced – to those zemstvo and city institutions that, due to their financial situation, were unable to use benefits on a general basis, such were provided in the amount of 75% of the expenses incurred. Since 1914, it has been possible to further increase the amount of the allowance relative to local expenses.

Despite the gradual evolution of the provisions of these laws in the interests of local self-government, the total amount of transfers allocated on their basis can hardly be considered adequate to local needs. So, in 1911, the bodies of zemstvo and city self–government applied for benefits in the total amount of 6.19 million rubles, in 1912 – for 4.13 million rubles, in 1913 - for 5.51 million rubles. The total amount of funds allocated to zemstvo, city and their replacement institutions for the specified three years amounted to 4.6 million rubles, or 29% of the amounts requested by them ^{[14, p. 229]}.

At the same time, the laws "On Improving Zemstvo and City finances" of December 5, 1912 and "On establishing a provision on preventive vaccination" of June 21, 1914, providing for subsidizing local health care costs on a more systematic basis, are being adopted. The first of them provided for the reimbursement of 1/3 of the expenses incurred from the zemstvo sums for the maintenance and treatment of the insane, the second – 1/2 of the zemstvo and city expenses for the opening and maintenance of smallpox calves, as well as for the temporary strengthening of the medical staff caused by the fight against smallpox epidemics (this provision was introduced into the text of the law on the initiative of the State Duma ^{[3, L. 85]}).

The listed laws, by and large, limited the subsidization of local health care costs in the pre-war period. Against this background, the reformers' proposals looked really large-scale and impressive. The most interesting in this regard is the draft Regulation on providing the population with public medical care – the most expensive of the projected reforms – which provides for the most complex financing mechanism.

In accordance with this Provision, county zemstvo assemblies and city dumas developed networks of medical sites (for counties), plans for public medical care (for cities with a population of over 55 thousand people) and financial plans for public medical care, after which they submitted them for approval by the General Directorate of Public Health.

In case of approval of these documents and acceptance by local self-government bodies of obligations to implement the set of measures developed by them in accordance with the procedure and deadlines established by the General Directorate of Public Health, they were granted the right to receive transfers from the state Treasury. The provision provided for three types of such:

• reimbursement of the amounts spent on the maintenance of medical personnel of medical institutions in the manner and amounts provided for in the financial plans;
• a one-time allowance in the amount of 100 rubles for the equipment of each hospital bed at the opening of each new medical institution;
• loans for the construction, expansion and reconstruction of hospital buildings.

According to the authors of the bill, allowances were to be allocated from the state Treasury, loans from a specially established hospital construction fund at the request of zemstvo and city institutions. The procedure for granting the latter has not been settled – neither the amount of loans, nor the grounds and conditions for their provision are known. There are reasons to believe that this issue could be resolved by analogy with the school construction fund.

In general, it is easy to see that the above provisions largely duplicate the financing mechanism for primary education reform. This experience was not completely alien to the healthcare sector either – similar mechanisms for the development of a network of medical sites naturally developed in the practice of individual provincial zemstvos. The most similar model was implemented in the Moscow province – the main difference was only in the costs, for which the provincial zemstvo allocated transfers to the county ^{[28, pp. 174-175]}. The degree of its effectiveness is clearly evidenced by the fact that it was here that the area and population of medical sites were closest to the optimal parameters.

As for the absolute values of the planned transfers, in the first year of the Regulation on providing the population with public medical care, it was supposed to allocate 23 million rubles for benefits and 20 million rubles for loans – for comparison, the largest total amount of benefits and loans allocated per year for the purpose of introducing universal primary education was 24 million rubles. It should also be noted that in 1913 the expenses of zemstvos for the medical part amounted to 70.22 million rubles ^{[6, p. 55]}, cities – 32.48 million rubles ^{[21, p. 129]}.

The draft laws developed by the G. E. Rein Commission assumed subsidizing of some other expenses of local budgets. In particular, it provided for the issuance of allowances for the implementation of measures to prevent and combat infectious diseases in the total amount of 5 million rubles per year (i.e. in an amount greater than was allocated for the same purposes from 1911 to 1913), reimbursement of part of the costs to medical institutions for the treatment of acute infectious diseases, etc. ^{[26, c. 21, 308]}

6. Conclusion. Ironically, the reform, which was based on the ideas of reconciling interests and reaching compromises, was rejected for purely political reasons. In the autumn of 1916, G. E. Rein persuaded Nicholas II to approve a bill on the creation of the General Directorate of Public Health in an extremely specified manner, on the basis of Article 87 of the Basic State Laws, which automatically turned deputies from the progressive bloc against him. The further escalation of the crisis in relations between the legislative and executive authorities predetermined the fate of the reform – on February 16, 1917, the bill was rejected by the Duma commission on public health without its consideration on its merits, and on February 22, G. E. Rein himself took the draft from the Duma.

Despite the fact that the healthcare reform has not been approved, its research is very productive for understanding the processes of political modernization in the last pre-revolutionary years. Its materials reflect many general trends in the development of Russian statehood in 1906-1917: the regulation of an increasing number of spheres of public relations, the formation of institutions of social policy, bureaucratization and unification of public administration, etc.

The analysis of numerous draft laws allows us to conclude that the reform project, on the one hand, quite organically fit into the context of pan–European trends in health policy at the beginning of the twentieth century, on the other hand, it sought to take into account, if possible, the long-standing traditions of Russian public medicine. The co-opting of representatives of zemstvos and cities into the processes of higher public administration, the creation of coordination and conciliation structures, recognition of the importance of preserving local initiative, the desire to institutionalize and scale the best of local practices, strengthening the financial base of local government – the constructiveness of the above measures is beyond doubt even from the standpoint of today, whereas in the realities of the early twentieth century, many of them they were almost revolutionary in nature.

As for the degree of adequacy of the reform under study to the problems of domestic healthcare and, as a result, the objectivity or subjectivity of the factors of its failure, suffice it to say that all the conceptual provisions proposed by the G. E. Rein Commission: the creation of an independent health management body, the accessibility of qualified medical care, the district principle of service, emphasis on sanitary and hygienic measures, public education in health issues, they were the basis of the Semashko system in the first years after the October Revolution and, with certain transformations, have been preserved to the present day. With this in mind, it would hardly be wrong to assume that the reformers suffered a tactical defeat at the moment, but won a strategic victory in the historical perspective.

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