With the abolition of serfdom in 1861, a real opportunity appeared for the development of rural health care. A zemstvo was an institution of local government set up during the great emancipation reform of 1861 carried out in Imperial Russia by Emperor Alexander II of Russia. The goal of the zemstvo reform was the creation of local organs of self-government on an elected basis, possessing sufficient authority and independence to resolve local economic problems. Alexander II instituted these bodies, one for each district and another for each province or government, in 1864.

In the period preceding the introduction of Zemstvo medicine, and in the initial period of its organization, treatment in hospitals and outpatient clinics cost 60 rubles per month. The reason for introducing free medical care was not only general humanitarian grounds, but also the practical observations of doctors that the establishment of even a minimum fee for medical advice and treatment in a hospital drastically reduces the demand for medical care, and this deprives zemstvo doctors of the opportunity to effectively fight epidemics. From the 1880-1890s, zemstvos began to refuse payments from patients - first at feldsher points, and then at doctor's appointments. Of course, free Zemstvo medicine cost a lot of money. If in 1868 they spent 1204 thousand rubles on medicine (8% of all zemstvo's funds), then in 1890 it was 9977 thousand rubles (21%) and in 1903 - 30,265 thousand rubles (28%) - significantly more than spending on anything else. By the beginning of the 20th century, paid treatment remained in 69 zemstvos and did not exceed 5-10 kopecks "for advice and medicine." According to data from 1907, zemstvos contained 2034 hospitals, in which there were 58,160 beds.

City Dumas, following the example of the zemstvos, also organized free outpatient medical care and the provision of medicines for the urban poor. The formation of medicine in municipalities was extremely uneven: according to research conducted at the initiative of the Pirogov Society, by the beginning of the twentieth century out of 258 European cities in Russia, medical assistance to the population was organized only in 26.3% of cities, and by 1914 - in 41%. While Zemstvo medicine inherited medical institutions and the resources of Departments (Prikaz) of Public Charity, cities had to create their own medical and sanitary organizations from scratch. The construction of city hospitals could afford only large industrial cities. Since the late 90s of the XIX century, the construction of urban medical institutions was carried out mainly with the money of philanthropists, but the further maintenance of hospitals and outpatient clinics was financed by city governments. The development of medical care in cities began with the organization of non-hospital aid the embodiment of which became the so-called Duma the doctors. They served the poor on a precinct principle and hosted at home. The next step was the creation of special outpatient clinics both at city hospitals and in the form of independent institutions. Inpatient care, organized by city governments, has achieved the greatest development in Saint Petersburg, Moscow, Kharkov, Odessa, where city hospitals met the level of modern scientific requirements.

The state also supported low-income citizens in providing free medical care. State hospitals provided free assistance to government officials and retired civil servants who receive less than 300 rubles a year and have no other means of livelihood. This right was also enjoyed by civil servants who had a family and lived in remote areas, even if their salary was above 300 rubles. Free medical assistance was received by the "lower servants" of the government departments, as well as "all ranks of the poor people, who would deserve special indulgence from them out of respect for their poor situation." The military departments paid for the treatment of military officials and their families. During cholera epidemics, all patients were served free of charge in civilian and military hospitals.

Sources: The issue of medical care accessibility in pre-revolutionary Russia, I.V. Yegorysheva, 2012; Zemstvo district medicine and charity in Russia, L.E. Gorelova, T.I. Surovtseva, 2014.