Nikolai Aleksandrovich Semashko

The system Semashko built in 1918 did not start from a blank sheet. Under the influence of zemstvo medicine, which appeared right after the emancipation of the serfs, awareness that a unified Russian state health system was needed spread in the second half of the 19th century, and the organisation of care on the territorial-district principle proved durable, lasting to the end of the Soviet period. Many zemstvo physicians' reception points later became rural feldsher-midwife stations (FAP). A special commission of the Interior Ministry, created at the end of the 19th century to find measures for the "universal improvement of Russia's health", was first chaired by Prof. S. P. Botkin, with the hygienist N. G. Freiberg handling its paperwork. Commission member Prof. G. E. Rein formulated the thesis of the need for centralized health administration through a dedicated ministry, which Nicholas II endorsed: Russia, "a sixth part of the world", could have a Ministry of Public Health. The commission ended its work with the start of the First World War.

At the end of 1916 an imperial decree established the Main Directorate of State Health Care with Prof. G. E. Rein at its head, its chancery led by N. G. Freiberg. In effect a ministry, the new body was to deal first with public hygiene and sanitation. But clashes of interest and political struggle led Duma parties and most practising physicians to oppose the reform, and in February 1917 the new structure was abolished without ever starting work. The idea of centralized medical administration itself survived the revolutions of 1917. This unsuccessful attempt and its suppression are the immediate political background to the 1918 commissariat.

After the overthrow of the Provisional Government and the end of the Civil War, the new communist state faced the question of how to organise a unified universal health system. The main role in posing that question and in creating the model and the institution of public health belonged to the physician and Bolshevik N. A. Semashko. From July 1918, as the first People's Commissar of Health of the Russian Socialist Republic, he directed the elaboration of the theoretical foundations of the entire state health system, relying on the materials of the "Most Highly Approved Interdepartmental Commission for the Revision of Medical-Sanitary Legislation". Although Soviet Russia did not publicise this continuity, the health reform was largely built on the commission's materials, including calculations of the required number of physicians, funding volumes and norms of provision.

In 1918 the highest medical body was the Council of Medical Colleges. On 10 July 1918 the 5th All-Russia Congress of Soviets listed the newly created people's commissariats in the RSFSR Constitution, including the People's Commissariat of Health. Thus for the first time in the world a supreme state organ was created that took charge of all branches of medical-sanitary affairs in the country. Officials of the abortive imperial Main Directorate of State Health Care were drawn into organising Soviet health care, and N. G. Freiberg played a large role in creating the normative base of the Commissariat. The ideas underlying Semashko's model were in many respects a continuation and development of ideas voiced during health reforms in the Russian Empire.

The task was immense. In conditions of civil war and devastation the new commissariat fought sweeping epidemics: about 80 per cent of soldiers returning from the front were infected with typhus. The most difficult organisational problems were solved, and the Soviet experience became to a degree a positive example for the creation of health ministries in a number of European states. Semashko himself dated the decisive earliest steps to June 1918: at the 1st Congress of Medical-Sanitary Departments he set out the principles of the new preventive-focused system in his report "On the Organisation of Soviet Medicine", and as the first People's Commissar of Health of the RSFSR and ideologist of the preventive direction he promoted from 1918 the emergence of the centre of medical education, the medical faculty of the 1st Moscow State University, which became the 1st Moscow Medical Institute in 1930.

In July 1918 a Sovnarkom decree nationalised all medical institutions in Russia and proclaimed free healthcare for all, launching the world's first nominally universal, free healthcare system. The model Semashko designed was a single-payer system funded from the state budget. The country was divided into medical districts (uchastoks), each assigned a multi-specialist district physician; complex cases were referred up a hierarchy of rayon, municipal, oblast, and federal hospitals. Its defining emphasis was preventive medicine: 'dispensarisation' (mandatory periodic screening), a unified sanitary-epidemiological surveillance network, and integrated maternal, infant, child, and adolescent health services. All physicians were salaried state employees (private practice was abolished) and curative, preventive, and sanitary work were unified under a single administrative hierarchy. By the late 1920s the core architecture was in place. Despite the devastation of civil war and the Great Patriotic War, the model drove down infectious disease mortality and sharply reduced infant mortality. It was adopted by Cuba, North Korea, and much of Eastern Europe. Although it later struggled with non-communicable diseases and uneven rural access, the principle of state-guaranteed universal health coverage remains a touchstone in international public health debates.