Health Care Planning

HEALTH CARE PLANNING. When beginning to draft a health care plan in a district (the same applies to a region or republic), it is necessary first of all to become familiar with the data characterizing the economic and sanitary-hygienic state of the district. The study of the district's economy is of particular importance for the plan, primarily because health care is called upon to serve the national economic plan and, through its measures, to facilitate the most successful execution of the latter. Setting for itself the task of facilitating the fulfillment of the industrial-financial plan, the health care plan must naturally be calculated to provide the best service to the most critical sectors of the national economic plan, and these sectors are: 1) industrial centers and new construction projects, 2) state farms, machine-tractor stations, and collective farms. Familiarization with the district's economy must proceed along the lines of studying individual, most important points of the district. The compiler of the health care plan must know in sufficient detail which enterprises exist on the territory of the district, the nature of their production, and the capacity of these enterprises; the same applies to enterprises newly under construction in the district. It is no less important to have an idea about the state farms located in the district, the nature of their production, and about the machine-tractor stations and the largest collective farms. The main indicators characterizing the sanitary-hygienic state of the district, which must be especially taken into account when drafting the health care plan, are: 1) general mortality and mortality of children under one year of age, 2) the morbidity of the population according to individual, most important forms of disease, 3) the state of housing and communal services, 4) the state of public catering, 5) the natural-geographic conditions of the district (swampiness, state of rivers, lakes, etc.). The most complex part of the health care plan is the correct assessment of sanitary-hygienic indicators, since the expediency of those measures which must be outlined to eliminate the sanitary-hygienic defects of the district will depend to a significant degree on the correctness of their assessment. The cited indicators, primarily morbidity and mortality, must be studied over a number of years, since data from only one year do not provide sufficient grounds for correct conclusions. Furthermore, these data must be compared with similar indicators for other districts, for the region, and for the republic as a whole. Only as a result of such comparison by year and with other districts is it possible to form an idea about the direction in which the development of sanitary affairs in the district is heading. Along with the general characterization of the sanitary state of the district as a whole, it is necessary when drafting the health care plan to become familiar with the sanitary state of individual parts of the district, to identify first of all individual foci of epidemic diseases so that, on the basis of these data, an operational plan for the sanitation of the district and its individual parts can be drawn up. In the presence of industrial enterprises, state farms, and machine-tractor stations in the district, the main attention when studying sanitary-hygienic indicators must be turned to these most important points of the district. After becoming familiar with the economy and the sanitary-hygienic state of the district, it is necessary to obtain information about the composition of the population of the district as a whole and its most important parts. Information about the population must be had in the following breakdowns: 1) the number of the population in the district by sex and the following age groups: a) from 0 to 2 years inclusive (nursery age), b) from 3 to 6 years (preschool age), c) from 7 to 14 years (school age), d) from 15 to 17 years (adolescents); 2) out of the total population—the number of insured persons; 3) the number of male and female workers employed in production, including by larger enterprises, for each of the latter individually; the same separately regarding female workers; 4) the number of nursery-age children of female workers, separately for those employed at larger enterprises, for each of the latter individually; 5) the number of permanent workers and—separately—seasonal and temporary workers on state farms; 6) the number of workers in machine-tractor stations; 7) the number of permanent female workers and—separately—seasonal female workers on state farms and machine-tractor stations; 8) the percentage of the collectivized population. The cited breakdown of the population is necessary so that, on the basis of these data and pre-established guidelines regarding the service of various groups of the population, individual parts of the plan can be built. Having received the information indicated above and analyzed it, it is possible to proceed to the concrete construction of the health care plan; the most important tasks which must be more fully reflected in the district's health care plan are: a) medical-sanitary service for workers of industrial enterprises, state farms, and machine-tractor stations, b) medical-sanitary service for the population of collective farms, especially during the period of agricultural campaigns. An operational plan for the fight against epidemic diseases, primarily typhus, typhoid fever, scarlet fever, diphtheria, and malaria, must be built in a special way. The main indicators which must be provided for in the plan for medical-sanitary service for workers of industrial enterprises are: a) health posts, b) outpatient and hospital networks, c) sanitary organization, d) nurseries. The question of organizing health posts is decided in accordance with the decree of the Council of People's Commissars of the RSFSR of May 16, 1931, according to which, at all enterprises where at least 250 workers are employed, economic organizations are obliged to provide equipped premises for health posts; according to this same law, enterprises numbering 500 or more workers must have medical health posts. More complex is the planning of shop-floor health posts at large enterprises. To resolve the question of these posts, the compiler of the plan must be familiar with the volume and nature of production, the main workshops of the latter, the composition of workers by workshop, detailed professions, sex and age, the sanitary state of the workshops, the location of the latter on the territory of the enterprise, and data characterizing the morbidity of the enterprise's workers by individual workshops.

The question of worker morbidity by workshop is clarified on the basis of materials from insurance funds, which, although they do not characterize all morbidity, nevertheless include all cases of diseases associated with temporary disability, i.e., the most serious cases of illness. When studying the morbidity of workers, it is necessary first of all to keep in mind the following groups of diseases, which, according to the statistics of insurance funds, account for up to 70% of all cases of temporary disability: a) infectious diseases, b) gastrointestinal diseases, c) diseases of the skin and subcutaneous tissue, d) industrial injuries. When drawing up a plan for outpatient care, the following questions are of particular importance: a) what types of outpatient care should be organized, b) what should be the volume of each of these types of care. The volume of outpatient care is determined, on the one hand, by the morbidity of the contingents to be served, and on the other, by those contingents that should be covered by the outpatient network as part of preventive care (in children's and women's consultation centers, children's preventive outpatient clinics, etc.). The number of these contingents depends entirely on the guidelines set for the planned period regarding the service of workers and their family members with individual types of outpatient care. The outpatient network is calculated based on: a) the number of visits that the contingents planned for will make during the planned period for each of the main types of outpatient care; b) the workload of the medical reception (the number of visits that falls to a doctor during a working day) for each of the main types of outpatient care; c) the number of days of operation of the medical reception during the year. In their practical work, health and planning agencies currently accept an average standard workload for medical reception in outpatient network institutions of 35 visits per day, with a lower standard for a number of specialties (dental, tuberculosis, etc.) and a higher one for surgical, dermatovenereological, etc., diseases. As for the annual operation of the medical reception, work for 350 days is accepted as the maximum possible, setting aside the remaining 15 days for repairs. The most important indicator of the outpatient network is undoubtedly the daily workload of the medical reception, since the value of this indicator, on the one hand, determines the volume of the outpatient network, and on the other, affects the quality of this type of care. The guideline that currently exists regarding this indicator boils down to the fact that in the future it is possible to even slightly increase the standard (on average up to 40 visits per day) by freeing the doctor from a number of functions that are currently performed by him during the working day and which should be transferred to paramedical personnel.

The plan for the hospital network in an industrial district must be built based on: a) data on the morbidity of various population groups (workers, members of their families, other insured persons, etc.) by individual forms of diseases; b) guidelines regarding the necessary coverage by hospitalization of patients with more frequent forms of diseases; c) guidelines regarding the realistically possible coverage by hospitalization of patients with more frequent forms of diseases for the planned period; d) the guideline for better hospital care for the industrial proletariat, as is the case with other types of medical and sanitary services; e) the average stay of a patient in a bed for each of the most frequent forms of diseases; f) the number of days of bed operation during the year (annual bed workload). Of particular importance for the hospital network plan is the question of beds by specialty, and this question is largely determined by the indicators cited above. Thus, the number of infectious patients subject to hospitalization during the planned period determines the number of infectious beds required for them according to the formula: [formula], etc.

where A₁, A₂, A₃... denote the number of patients with different infections subject to hospitalization, K₁, K₂, K₃... the average stay of a patient in a bed, L₁, L₂, L₃... the annual bed load. The necessary number of beds for other specialties is determined according to the same scheme. Determining the number of necessary maternity beds is extremely simple. Proceeding from the goal of full coverage of hospitalization for women in labor in an industrial center and guided by the birth rate figures therein, assuming an average stay of a woman in labor in a bed of 7-8 days and an annual bed load of 325-330 days, it is easy to determine the necessary number of maternity beds. One of the complex issues in the planning of the bed network is the question of the average stay of a patient in a bed. This average depends on a whole range of factors: the nature of the diseases, the specialization of the beds, the organization of work in the hospital, etc. Data from the medical census conducted in 1930 indicate that with an average stay of a patient in an urban bed in the RSFSR of 13.4 days, the Moscow and Leningrad regions show significantly higher figures, and along with this, the majority of krais and regions show figures below the average for the republic. The experience of individual hospitals shows that rationalization measures can influence the reduction of the average stay in a bed without detriment to the patient (preparing the patient before admission to the bed, more frequent operating days, earlier discharge of certain categories of patients with patronage at home, etc.).

In the planning of the nursery network, it is necessary to proceed from the goal of priority service by nurseries for the children of women employed in production; the contingents of these children are taken into account first and foremost. Along with them, children of nursery age of other women, workers and employees, and children of students are taken into account, and from the very beginning, it is necessary to have a target regarding the degree of coverage of each of the indicated categories of children with nursery service, which determines the volume of the nursery plan. The nursery plan is built based on the goal of serving all shifts at the enterprise. Regarding the duration of a child's stay in the nursery, the plan provides for round-the-clock nurseries, where the child remains for 24 hours, nurseries with a long stay for the child, and shift nurseries, in which all beds or part of the beds operate in two or more shifts. In our healthcare plans, the specific weight of round-the-clock nurseries and nurseries with a long stay for the child increases every year. The question of the location for building nurseries depends primarily on which contingents the nurseries are intended for. To serve infants, nurseries should be built in the immediate vicinity of enterprises (preferably not on the territory of the enterprise) so that the working mother can feed the child during her allotted break; regarding the other two age groups, the mother's place of residence is taken into account first and foremost.

The plan for sanitary-epidemic measures is one of the most important parts of the healthcare plan. A number of government decrees (on the sanitary minimum, on the fight against epidemics, on standards of sanitary service, on public catering, etc.) specifically outline the measures that must be provided for in the healthcare plan regarding the sanitary improvement of the country. The most important measures are: 1. Hospitalization of infectious patients. The healthcare plan must outline the number of necessary contagious disease beds, proceeding from a pre-established target regarding the coverage of hospitalization for various infectious diseases. (The method for determining the necessary quantity of beds is given above.) 2. Disinfection and disinsection work. When compiling this part of the plan, it is necessary first and foremost to be guided by the standards of sanitary service established by the decree of the Council of People's Commissars of the RSFSR. These standards provide for the capacity of disinfection institutions in various districts, depending on the importance of the latter, the social composition of the population, etc. Along with this, the question of organizing disinfection work is decided depending on the epidemic nature of the district and the presence of epidemic foci in it. 3. Vaccination work. The healthcare plan provides for the following types of vaccinations: a) smallpox, b) typhoid fever, c) scarlet fever, d) diphtheria. Smallpox vaccinations are provided for in the plan based on the calculation of full coverage of unvaccinated contingents, as well as those requiring revaccination. As for the other vaccinations, their quantity depends on the presence of one or another epidemic in the district, and regarding typhoid fever, the vaccination must be calculated primarily for the population of the affected parts of the district, and regarding scarlet fever and diphtheria vaccinations, for organized groups of children. 4. In relation to the fight against epidemics, primarily typhus, sanitary-checkpoints and bath-disinfection detachments acquire special importance. The plan provides for sanitary-checkpoints primarily in places of large concentrations of incoming population and moving masses (new construction sites, railway junctions). Bath-disinfection detachments are planned for deployment in areas threatened or affected by an epidemic that are not provided with baths and disinfection work (peat extraction, other seasonal work, etc.). 5. Sanitary inspection, state and public. Regarding sanitary inspection, the plan is guided by the decree of the Council of People's Commissars of the RSFSR of August 10, 1931, on sanitary inspection. Of special importance is the planning of public sanitary inspection, as the latter must become the basis of that public activist group which is called upon to assist healthcare bodies in every possible way in the matter of fighting epidemics. Sanitary inspection is planned according to its individual special types: housing and communal, food, industrial; doctors-epidemiologists are planned separately.

A very essential part of the sanitary improvement plan is sanitary-cultural work. The main types of this work, which are provided for by the plan, are sanitary exhibitions—stationary and mobile, lectures and talks on sanitary issues, leaflets, brochures, participation in the press, films, etc. Along with the cited measures, which are carried out according to the plan of healthcare bodies, measures carried out according to the plans of other departments (housing and communal affairs, public catering, school affairs, hydraulic engineering and hydro-reclamation works, etc.) are of exceptional importance for the sanitary improvement plan of a district. The main task of healthcare bodies is to exert influence in every possible way on these plans, proceeding from the concrete tasks of the sanitary improvement of the district, primarily in terms of bath and laundry work, water supply, sewage, coverage by public catering and the qualitative improvement of the latter, hydraulic engineering and hydro-reclamation works, etc. This constitutes the construction of a complex plan for the sanitary improvement of a district. The main indicators that must be taken into account in the rural healthcare plan are the following: 1) outpatient and hospital service, 2) nursery work. Regarding state farms, the cited types of service are planned in such a way as to ensure as fully as possible the basic types of assistance for the male and female workers of the state farms. The compiler of the plan must proceed from the necessity in larger state farms, numbering 500 or more permanent workers, to have a medical outpatient clinic, a hospital with 35-40 beds for the main specialties, as well as permanent nurseries to serve primarily the children of female workers permanently employed in the state farms, and seasonal nurseries for the children of seasonal and day laborers. The cited service standards are not mandatory for those state farms in the immediate vicinity of which there are main medical-preventive institutions; on the other hand, the compiler of the plan, when building a hospital and outpatient clinic in a state farm for the purpose of bringing these types of assistance closer to the state farm workers, must keep in mind that these institutions will be used to a greater or lesser extent by the peasant population surrounding the state farm. Keeping this in mind, it is necessary to reflect this tendency in the plan by enlarging the construction of the medical-sanitary network in state farms, so that this network, while serving the state farm workers first and foremost, simultaneously serves the rest of the population, primarily the collective farm population.

The plan for medical-sanitary service of agricultural campaigns provides for the following main measures: a) medical brigades, b) points

b) first aid stations, c) first aid kits, d) seasonal nurseries. Along with these measures, the plan must take into account the need for greater adaptation of the existing network in the countryside to the needs of agricultural campaigns. Extremely important for the rural health care plan is the question of the direction in which the development of health care will proceed there in the coming years. The completion, in the main, of the process of collectivization of agriculture and the provision of a solid technical base for agricultural processes should also sharply affect the medical and sanitary organization of the village. The influence of these processes on health care should be felt primarily in terms of improving qualifications and the specialization of care. The strengthening of the specialization of care should lead to a significant consolidation of the network in the countryside, and this consolidation of the network should be carried out primarily in the district administrative center, which, as a rule, is also the energy center of the district. This applies primarily to the outpatient and hospital network. This circumstance must be taken into account already at the present time when drawing up a rural health care plan. The question of nurseries must stand separately in the rural plan. Here, the planner faces the task of outlining the greatest possible development of permanent nurseries and, along with this, ensuring the greatest possible coverage with seasonal nurseries for the children of peasant women employed in agricultural campaigns. The question of converting more seasonal nurseries into permanent ones, in addition to the greater expediency of the latter from the point of view of service, is also of particular importance from the point of view of retaining medical personnel in the nurseries. One of the most important parts of the plan is the nominal lists of construction, since they reflect the concrete development of various branches of health care and make it possible to judge the content of the plan from the point of view of serving various groups of the population, primarily workers in leading industries. In this regard, it is important that the nominal lists include the greatest possible number of points of the medical and sanitary construction outlined by the plan. The most essential part of the health care plan, which largely determines the volume and content of the plan, is the plan for medical personnel—doctors and paramedical staff. The plan must determine the need for medical personnel and the ways to realistically meet this need. Despite the enormous growth of medical universities and technical schools in recent years, the need for medical personnel, arising from the large growth of the medical and sanitary network, is not fully covered by the graduates of medical institutes, and the health care plan year after year provides for covering a significant number of medical positions in cities through dual employment. The financial plan for health care is built on the basis of the outlined medical and sanitary network and the tentatively established standards for the cost of individual types of service for the planned period. It is characteristic that wages account for more than 50% of all health care expenditures. As for expenditures on individual branches of health care, in recent years the plan has provided for an increase in expenditures on sanitary and preventive work at the expense of a certain reduction in the specific weight of medical work in the general expenditure budget. Year after year, a sharp increase in expenditures on nursery work is noted. As for the sources of financing for health care, the main sources are the medical aid fund for the insured and the local budget, which together account for more than 80% of the entire financial plan.