Medical District (a territorial unit for providing medical care)

Medical District, a territorial unit for providing medical care to the population. A medical district is a physician-led association of medical-sanitary institutions located in a specific rural area and serving the healthcare needs of the population of that area; these are so-called rural medical districts (often called medical districts). A medical district can also refer to a medical-sanitary organization consisting of a number of therapeutic, sanitary, and preventive institutions located in a specific city district and serving that district (hospitals, outpatient clinics, home care points, dispensaries, nurseries, consultations, laboratories, disinfection facilities, sanitary-educational exhibitions, etc.); in this case, it is referred to as an urban medical district. Urban medical districts are often called district medical-sanitary or district physician-sanitary organizations. In Moscow, such medical districts are called district outpatient associations (see Outpatient Care), as the guiding center of the district association of therapeutic and preventive institutions in Moscow is usually the corresponding district specialized outpatient clinic. On the railroad, a medical district is the aggregate of medical institutions serving a specific railroad area of a certain length. Origin and development of medical districts. Rural medical districts began to be established in Russia only after the introduction of zemstvos (1864). Until the 1860s, the provision of medical care to peasants in provinces with a sufficient number of state or state peasants was entrusted to feldshers (physician's assistants), mostly of low qualification, with one feldsher in many places covering 2-3 or more volosts (administrative units). In some places, reception rooms with 2-5 beds were maintained at feldsher posts. Although there existed district physicians, one for 3-5 uyezds (districts), who were supposed to supervise the provision of medical care in rural areas, there was virtually no supervision of the activities of feldsher posts, as physicians rarely managed to visit even a portion of them. Serf peasants, however, were deprived of medical care, except in those rare cases when landowners maintained feldshers or, which happened very rarely, physicians with hospitals. State peasants, who constituted about half of the rural population, were served by 791 feldsher posts and 84 reception rooms with 269 beds. Soon after the organization of zemstvos, uyezds were divided by them into districts, to which individual physicians were invited. These physicians did not have permanent residence at any rural medical post, but had to provide medical care to the population, moving from place to place, and take measures to prevent the spread of epidemic diseases. Physicians spent all their time traveling around their medical district. This is the so-called "traveling system" of organizing care in the medical district, which entered the history of Russian medicine under this name. Its essence was that special points were designated in the districts, to which physicians periodically traveled on predetermined days, while constant care was provided by a network of zemstvo-organized feldsher posts with permanently resident feldshers. The latter were also required to report to physicians about the occurrence of epidemic diseases. Soon, however, it was established that the traveling system did not at all meet the requirements for the rational organization of medical care to the population, and in the 1880s, the traveling system of organizing medical districts began to be gradually replaced by the so-called stationary system. Zemstvos began to establish networks of medical districts in uyezds such that, whenever possible, a hospital with a maternity ward and an outpatient clinic was opened in the center of the medical district area, and in many areas also with an infectious disease barrack, with physicians permanently stationed at these medical districts, whose duties included providing outpatient and inpatient care, visiting seriously ill patients to provide home care, traveling to villages where epidemic diseases appeared to take appropriate measures, organizing smallpox vaccination, implementing school sanitary supervision, disseminating hygienic knowledge, and conducting sanitary measures. The first rudiments of the stationary system of organizing medical districts appeared in some uyezds (Stavropol uyezd of Samara province, Moscow uyezd, etc.) as early as the beginning of the 1870s. Already in 1890, according to Zhbankov's data, the traveling system remained only in 50 uyezds of zemstvo provinces, in 46 uyezds the stationary system existed, and in 258 there was a mixed system, i.e., along with medical districts headed by physicians with hospitals and outpatient clinics, there were also outpatient and feldsher posts to which the physician traveled at specific times to provide medical care. The stationary system of organizing medical districts became predominant in subsequent years. The development of the network of medical districts in zemstvo provinces proceeded as follows: Table 1. Network of Medical Districts 1880 1890 1900 Total number of medical districts 925 1,440 Of these: with hospital in rural areas 370 890 1,710 (13%) (40%) (47%) (54%) (64%) with hospital in district towns 310 315 Physicians per medical district without inpatient treatment 245 435 (25%) (27%) (30%) (29%) (24%) Average area of medical district in sq. km 3,050 1,980 After subtracting uninhabited area 1,070 Population per medical district in thousands 33 28 Number of beds per 10,000 population per medical district 1.5 2.5 3.4 4.0 4.8 Number of independent feldsher posts 2,620 Number of independent feldsher posts per medical district 2.8 2.5 1.75 The network of medical districts was extremely inadequate. In 1910 (3. G. Frenkel, "Zemstvo-Medical Affairs"), even in these provinces, only 30% of the area of zemstvo provinces was actually served by medical care in terms of comparative accessibility (radius 10 km), and 48% of the entire area of zemstvo Russia accounted for populated areas completely unserved by medical-sanitary care. In zemstvo provinces, one medical district accounted on average in 1910 for an area of 755 sq. km (after subtracting uninhabited areas) and about 28,000 people, with many provinces having an extremely inadequate network. In non-zemstvo provinces, where the government as early as the 1880-1890s began to organize the so-called "rural medicine" placed under special supervision of government agencies, one medical district accounted for an area of 2,300 sq. km on average and 98,000 people. In the Caucasus, one medical district covered an area of 3,100 sq. km and 73,000 people. The situation of medical care in rural areas on the eve of the imperialist war was no better. On the territory corresponding to the current RSFSR, in 1913 there were 2,732 medical districts (according to data from the Reina Commission for reviewing medical-sanitary legislation - 2,517) and 3,325 feldsher posts. The network of medical districts in the USSR. In 1926-27, on the territory of the RSFSR, there were already 4,341 medical districts, of which 2,656 were hospital medical districts with 61,990 beds. In addition, there were 3,478 independent feldsher posts. The average radius of a medical district in the RSFSR, including the very sparsely populated areas of Siberia, the Far East, etc., is about 38 km, with a medical district population of about 20,000 people. When evaluating these figures, it should be borne in mind the great variation in the size of medical districts in different regions; for example, in the Moscow province the radius of a medical district is 2 km, in the Crimean ASSR it is 9 km, while in Siberia it is 40 km, and in the Yakut ASSR and Kazakh ASSR it reaches even 100 km. The network of medical districts is significantly larger than the pre-war one, and in it the number of medical districts sharply predominates over the number of feldsher posts, whereas in the pre-war period the opposite ratio was observed (see Table 2). The existing network of medical districts includes many preventive institutions that medical districts did not have before the revolution. The utilization rate of rural population in outpatient clinics of medical districts per year was in 1913 - 4,467 per 10,000 population, and in 1926 - 6,243, which also speaks to the great accessibility of care to the rural population. The network of medical districts has been constantly growing in recent years, and besides the expansion of new medical districts in areas, there is a replacement of feldsher posts with physician-outpatient districts and the opening of hospitals on physician-outpatient districts. The growth rate of the medical district network can be seen from the comparison of Tables 3 and 4. The previous growth rate of the medical district network by decades for 34 zemstvo provinces was significantly smaller, as can be seen from Table 4. Table. Medical Districts Rural physician districts. Of which hospital ones. Beds in them. % of rural physician districts having hospitals. Independent feldsher posts. % of feldsher posts to medical districts. 61.1 42.0 - a в O) a в 48.2 38.8 11.4 55.4 50.0 40.7 24.8 97.4 a б л. 3. 1913 g. 1925g. 1926 g. 1927 g. Number of medical districts Changes in percentage Number of district hospitals Changes in percentage Number of physician outpatient districts. Changes in percentage 3,549 +41 2,421 1,128 4,098 +13.4 2,596 +7.8 1,502 +33.1 4,341 +5.9 2,656 +2.3 1,687 +12.3 Tabl. 4. Average annual % increase of medical districts in 34 zemstvo provinces 2. Network of medical districts in the USSR in 1926/27 g. on DOMU (general treatment.

(provision of medical assistance and its main special forms), implementation of therapeutic and preventive measures to combat social, domestic, professional, and epidemic diseases (in the latter case - sanitary measures, preventive vaccinations, disinfection, isolation of the sick, etc.), organization and implementation of measures to protect motherhood, infancy, and the health of children and adolescents (with special attention to the fight against child mortality, implementation of school medical supervision, hygienic education of the younger generation, and measures for physical culture), dissemination of sanitary-hygienic knowledge and development of sanitary skills among the population (raising sanitary culture), registration and accounting of morbidity, study of the sanitary condition of the district's territory and living conditions of the population, and implementation of special surveys of the health status and working and living conditions of certain categories of the sick and certain population groups (for the purpose of detecting natural, social, and domestic causes of morbidity and taking appropriate measures to combat them), implementation and participation in measures to improve the working and living conditions of the population, implementation of general sanitary supervision (current and preventive), especially to improve the sanitary condition of rural areas (supervision of water supply, housing, public places, removal of waste, etc.), care for the mentally ill (patronage) located on the territory of the district, participation in general cultural work in the countryside and organization of self-activity of the rural population in the field of healthcare. The medical district, by the nature of its activities, should be an organizing and guiding center for all healthcare activities in the territory it serves, satisfying all the basic needs of the population for medical-sanitary assistance, with special attention to preventive measures. Rural medical districts are divided into medical-hospital districts and medical-outpatient districts; the former include a hospital, while the latter do not. If there are feldsher (paramedic) stations (medical outpatient points headed by feldshers) on the territory of the medical district, they are part of the district and subordinate to it. The network of medical districts forms the rural medical-sanitary organization, which is often called the medical-sanitary district network or the rural district healthcare network. Each properly organized medical district must have at minimum: an outpatient clinic, a stationary facility (infirmary) for general patients, an infectious diseases department with a disinfection chamber, a maternity department, a pharmacy, and transportation means for providing medical assistance to the population at home - mobile assistance. District and volost (township) medical districts, organized in accordance with the administrative (Data development 3. G. Frenkel) Decade of Medical Districts District hospitals Doctor outpatient districts 1870-1880 . . . 1880-1890 . . . 1890-1900 . . . 1900-1910 . . . 2.16 6.18 4.3 3.54 18.4 6.37 5.64 3.51 5.65 5.88 1.14 2.59 However, at present, there are still 15% unfilled vacancies for doctors in medical districts. In the RSFSR, only 26% of medical districts are currently provided with transportation means. Salaries for personnel are still insufficient, and the material and domestic needs of medical districts are still not fully met. The efforts of government bodies and Soviet public opinion are directed toward promoting the further development of a network of medical districts close to the population, which not only provides free accessible qualified medical assistance but also carries out preventive and health measures to protect and strengthen the health of the rural population. The successful growth of the national economy and the growth of the budget, as well as the increased attention of Soviet public opinion to the needs of rural healthcare, guarantee the further correct development of the network of medical districts. Tasks of the rural medical district. The tasks of the rural medical district include the free provision of medical assistance to the rural working population on an outpatient, inpatient, and home basis, as well as the division and location of corresponding district and volost centers, which form the basis of the normal district and volost healthcare organization. The normal district or volost healthcare organization is structured so that each district, volost, or normal district and volost medical districts have: 1) at least one hospital with an outpatient clinic, maternity and infectious diseases departments, a dental office, and a pharmacy; 2) a consultation center for mothers and infants, as well as summer nurseries; 3) venereal, tuberculosis, and ophthalmology beds and other appropriate types of medical assistance in districts and volosts affected by syphilis, tuberculosis, trachoma, and other domestic diseases; 4) a playground for physically weak children; 5) basic sanitary institutions - the simplest disinfection facility, an institute for vaccinators, and a mobile exhibition for sanitary education. In districts (volosts) where, due to the extensive territory or other reasons, the hospital of the district or volost medical district cannot serve the entire population of the district or volost, additional medical-outpatient or medical-hospital districts are organized as their constituent parts on the territory of the aforementioned district or volost medical district (resolution of the VTsIK and Sovnarkom of December 14, 1925, on the foundations of the construction of volost and district healthcare organizations). Tuberculosis dispensaries, tuberculosis stations, venereal teams, venereal stations, nurseries, consultation centers, ophthalmology teams, and other special medical-sanitary institutions serving the rural population on the territory of the medical district are part of the latter, coordinate their work with the work plan of the medical district, and work under its general guidance in accordance with the directives of healthcare authorities in the relevant areas of work. These special institutions carry out work on the territory of the medical district on a dispensary basis, with household, family, individual, and selective examinations, which are conducted by these institutions in relation to tuberculosis, syphilis, trachoma, etc., being coordinated with the district, and the corresponding family and household registration records and examination results should become the property of the district and be included in the general family records kept on the medical district, so that observations and measures in relation to specific diseases are not isolated from the general observations and measures of the district. If these special institutions are not available, the corresponding dispensary-type work falls entirely on the general medical-sanitary institutions of the district, but in this case, the district usually selects from the entire population certain groups for more in-depth service according to different criteria: 1) by age (covering children, especially infants, adolescents, organized groups - children's institutions, schools, pioneer detachments); 2) by sex (rational service with consultative and therapeutic assistance to pregnant women and nursing mothers); 3) by profession (registration and supervision of the most vulnerable groups of the population - agricultural workers of state farms, farm laborers, engaged in crafts, etc.); 4) by the criterion of the most common diseases in the given area (tuberculosis, syphilis, trachoma, etc.). A normal rural district (volost) medical-sanitary organization or a normal district (volost) medical district should have a district (volost) sanitary doctor to direct all sanitary activities in the territory of the district (volost). It is necessary that the medical districts included in the rural district (volost) medical-sanitary organization be built, if possible, according to the type of normal medical districts; such districts are considered to be those with a radius of no more than 8-10 km, with a population of 8-10 thousand people, providing the latter with free, accessible, sufficiently qualified medical assistance - therapeutic (outpatient, inpatient, and home care) and preventive in accordance with established norms, and carrying out the necessary preventive and health measures. When expanding the network of normal medical districts, the opening of new feldsher stations is not permitted, while old feldsher stations are to be converted into medical stations or closed down, if, according to the new plan for the construction of a normal network, medical stations are not to be retained in the location of the feldsher stations. Standards of territory and population for medical districts. When organizing a network of normal medical districts, the following guidelines are used. It has been established that the normal rate of population seeking medical assistance in rural medical districts, equal to 100% of the population per year, exists in a medical district not exceeding 5-6.5 km in radius, whereas in the next concentric zone, from 6.5 to 12.5 km in radius (counting the center as the location of the district hospital or outpatient clinic), the annual rate of population seeking medical assistance is already below 50% of its size, and further decreases progressively with distance from the said center. The medical district, in order to ensure accessible medical assistance, should have a territory with a radius not exceeding 10 km, as from areas beyond this radius, the rate of population seeking medical assistance sharply decreases.

Since a Medical District (M.D.) with one physician (which is the case for the vast majority of districts) can, under a normal physician workload, accommodate only 35-40 outpatients per day or about 10-12 thousand visits per year (of which 5-6 thousand are initial), and since the total number of all visits in a normal-sized Medical District usually exceeds the population of the M.D. by 1½ times, then the figure of eight thousand population should be considered the maximum for an M.D. with one physician, with a radius of up to 10 km, i.e., with an average density of 25-30 people per 1 sq. km. The standard population size for a district to ensure accessibility of outpatient care should average 6-8 thousand people. In rural areas with higher population density, as well as in rural areas with developed industry and a large concentration of agricultural workers, the amount of medical and auxiliary personnel of the M.D. is correspondingly increased, or its territory is reduced by organizing additional medical points. In areas with sparser population (less than 25 people per 1 sq. km), the area of the M.D. is increased as necessary, but it is considered completely unacceptable to increase the radius beyond 15 km, i.e., beyond 700 sq. km of territory of the M.D. In such cases, an additional medical-hospital or medical-outpatient district should be organized. Standards for inpatient care. For a medical district per 1,000 population, the following are necessary: for internal medicine and surgical hospitals, 2 beds; for infectious diseases, 0.5-1; for maternity cases, 0.5; for eye diseases, 0.1; for venereal diseases, 0.1 beds. An M.D. with 8,000 population should have 25-30 beds, of which 15-16 for surgery and therapy, 4-6 maternity, and 4-6 infectious. Maternity and infectious beds (isolation-epidemiological) as beds of preventive value must be present on each district. Exception is permissible only for those medical-outpatient districts that serve a territory with a radius of less than 8 km. The above standards are increased for M.D.s located in areas with developed industry or with a large concentration of agricultural workers, with the aim of approaching the standards of medical care established for the insured. The concept of general inpatient care in an M.D. previously usually covered therapeutic and surgical beds; now, according to the 'Instruction of the People's Commissariat of Health on the preparation of a plan for the normal provincial network of medical-sanitary districts' published in 1925, the concept of general inpatient care in an M.D. includes maternity, isolation-epidemiological, and first aid beds, of which according to this instruction it is necessary to have in an M.D. at the rate of 1 bed per 500 population, i.e., a normal M.D. should have 12-15 such general care beds (besides special beds), and this number includes 4 infectious, 4-6 maternity, and the rest first aid beds; beds for other specialties should be 10-15, with their distribution according to the given coefficients. The type of a small hospital for an M.D. should be a hospital with 16 beds, of which 8 surgical and therapeutic, 4 maternity, and 4 isolation-epidemiological. The calculation of inpatient care is based on data from the activities of the best-equipped rural clinics of the Moscow province, showing that out of 100 patients applying to the outpatient department, on average about 7, in the absence of epidemics, require admission to a bed, with an average duration of stay of a patient in bed of 14 days. The calculation of the need for maternity beds is based on the average birth rate of 4% of the population, and on the assumption that one bed can serve about 50 maternity cases per year and that 60-70% of all births will occur in the maternity department. The coefficient of need for infectious beds is calculated on the basis of empirically established data that an average M.D. with a population of about 10,000 isolates annually about 130 acute infectious diseases (typhoid, scarlet fever, smallpox, diphtheria, etc.), and that an infectious bed can accommodate 16-17 patients per year. As for eye and venereal beds, the given coefficients in places with strong spread (especially household) of eye and venereal diseases are correspondingly increased, in accordance with the identified need. In relation to the mentally ill, the district M.D. organizes patronage at the rate of 0.4 per 1,000 population. In relation to dental care, each district (volost) M.D. should have a dental office conducting therapeutic and preventive work in dentistry. Thus, the district (volost) physician, district should have: an outpatient clinic, a pharmacy, 12-45 general beds (maternity, infectious, and first aid) to serve these types of care for a territory with a radius of 8.5-10.6 km (with an average density of 25 people per sq. km), then special beds (according to the given coefficients) to serve the entire territory of the district M.D., a disinfection chamber, a consultation for pregnant women and infants, nurseries, a dental office, a sanitary-prophylactic exhibition, and transport with two horses. The staff of the district (volost) M.D. is determined by the number of beds, the load of outpatient and visiting work, the nature of preventive work, but in any case, the staff should consist of at least two physicians, one dentist, three persons of medium medical personnel, two midwives, and two nurse-investigators, and a certain amount of caring and domestic personnel, according to workload standards. A normal district (volost) M.D. should have one sanitary physician. Additional medical-hospital and medical-outpatient districts within the territory of the district (volost) M.D., being part of the latter and coordinating their work with it, provide therapeutic outpatient and inpatient care and home care, as well as preventive care to the population on the same basis as the main district (volost) M.D., and in the additional medical-hospital district the number of beds should not be less than 4 maternity, 3-4 isolation-epidemiological, and 4-6 for providing first aid, and a consultation for pregnant women and infants should be organized. The medical personnel of such an additional M.D. consists of two physicians, at least two persons of medium medical personnel, two midwives, and one nurse-investigator. The transport of such a district should be provided with two horses. A medical-outpatient district should have a minimum of one physician, two persons of medium medical personnel, one midwife, and one nurse-investigator. As for the existing regulated minimum staffs of M.D.s, they were established in 1923, mainly taking into account their medical work; for a medical-outpatient district as a minimum - one physician, three persons of medium medical personnel (of which one midwife-nurse) and one servant or worker. For a medical-hospital district up to 15 beds - one physician (if the number of visits per year exceeds 10 thousand, then a second physician is assigned), 3-4 persons of medium medical personnel (of which one midwife-nurse), 4-6 persons of junior caring personnel, depending on the number of beds and the presence of an infectious department, one cook, one laundress, and one servant or worker. With the number of beds in the physician's district of 16-30 - two physicians; 5-6 persons of medium medical personnel (of which 1-2 midwife-nurses), one pharmacist, one head of household or housekeeper, 6-9 persons of junior caring personnel, one cook, one laundress, and two servants or workers. With the number of beds in the M.D. over 30, additionally for every 15-20 beds - one physician, two persons of medium medical personnel, 3-4 junior and 1-2 other domestic personnel, one dentist, one disinfection attendant, and one office clerk-registrar. To ensure the fulfillment of preventive and sanitary tasks of the M.D., especially with one physician, in addition to the above staff, one more physician should be added.--On many M.D.s, so-called 'preventive days' are allocated for conducting sanitary and preventive work, during which special attention is paid to issues of sanitary education, protection of motherhood, infancy, and childhood, and sanitary improvement (lectures, conversations, examinations, consultations for pregnant women and mothers, etc.). The most powerful M.D.s with several physicians and special preventive cells (such as consultations, nurseries) should have in their staff separate physicians for the most important areas of preventive work, for example, a physician conducting work on the protection of motherhood and infancy, a venereologist in areas with significant spread of venereal diseases, etc. The construction of the M.D. network is determined by a series of resolutions of government bodies and legislative acts - resolution of the Council of People's Commissars of the RSFSR of 30/VI-1924, resolution of the XII Congress of Soviets of the RSFSR on the report of the People's Commissariat of Health, decree of the VTsIK and Council of People's Commissars of the RSFSR of 2/XII-1925 and 14/XII-1925, resolution of the VTsIK and SNK of the RSFSR of 26/11-1926 on the report of the People's Commissariat of Health, and decree of the VTsIK and SNK of the RSFSR of 8/II-1927.

The expenses for maintaining the Medical District are imposed with respect to medical and feldsher outpatient clinics, midwifery care, children's nurseries and children's consultations—on the volost and corresponding budgets, and with respect to the establishment, equipment and maintenance of hospitals in rural areas and hospital construction in rural areas—on the uyezd and corresponding budgets (Regulation on Local Finances of the RSFSR, approved on November 19, 1926). However, in many provinces there is a tendency to impose the maintenance of rural hospitals on the volost and corresponding budgets. When constructing a network of normal Medical Districts—within the framework of the rural district medical-sanitary organization—it is necessary to operate with a number of characteristics determining the nature of the Medical District, namely: the population size, the total and actually populated area and the density of the territory to be served, the average radius, the average distance of settlements from the district institutions, the average proximity of residents to these institutions, the rate of population seeking medical help, and the attendance rate. The total area of the Medical District is understood to be the entire territory of the district. The total area of an existing district is determined as follows: on a map of the district (uyezd) with a 5-verst scale, around each outpatient clinic or hospital, a circle is drawn with such a radius that adjacent circles overlap each other, while the radii of the circles of two adjacent districts must be the same. Then, by connecting the points of intersection of the circles with straight lines, a series of polygons with a different number of sides of unequal length are obtained. All settlements remaining within such a polygon will be closer in a straight line to the outpatient clinic or hospital of this district than to the institutions of the adjacent district. The area of such a district is calculated using a planimeter. The actual area or actually populated area of the Medical District is obtained as follows: all empty uninhabited spaces of the Medical District (forests, swamps, flood meadows), separating the district from adjacent districts, as not affecting the rate of population seeking medical help, are subtracted from the total area of the district up to the peripheral settlements in the district. Then, the outermost settlements in the total area of the district are connected with a broken line, with the possibility of concave angles not excluded if they are not less than 90°. The resulting area of the polygon enclosed by the broken line is the actually populated area of the district, the calculation of which is also performed using a planimeter. The most important characteristic characterizing the actual distances in the territory of the Medical District, affecting the rate of population seeking medical help, is the geometric, or average radius. The geometric, or average radius of the actual area of the district is called the radius of a circle (inscribed polygon), the closed line of which passes through the outermost settlements of the district and is determined by the area of this circle. According to the definition by V. S. Lebedev, the geometric (or average) radius of the district is conventionally called the radius of a circle whose area is equal to the territory of this district. To characterize the location of the district institutions in relation to its boundaries, the maximum and minimum distances from the district institutions to its boundaries are noted. The average area per settlement is obtained by dividing the actual area of the district by the number of settlements in the district. To obtain an idea of the location of settlements in the territory of the district, the average distance between settlements is calculated, which equals