Accessibility of basic medical care for the local population was one of the key goals of zemstvo medicine, including in the Perm province. But in the extensive historiography on the problems of local selfgovernment there are no works containing concrete results of the implementation of this important principle in a comparative perspective. In the article, such an analysis is carried out on the example of the Perm province on the eve of the First World War. In the early 1910s. its county zemstvos have developed projects of optimal networks of medical sites that would make it possible to ensure the accessibility of basic medical care to the population. They naturally took into account the activities of other actors in the health sector of the region: a number of departments, plant administrations and city self-government bodies. The authors' analysis of the zemstvo projects of the optimal network of medical sites showed similar results. For the real accessibility of medical care in the Perm province, their number almost everywhere should have been increased at least twice, and in the foreseeable future three times. To do this, it was necessary to find new sources of funds in the conditions of a chronic shortage of zemstvo budgets, including the provincial one. In addition, it was not necessary to count on a significant expansion of the network of departmental and city hospitals in the Perm province. Therefore, the implementation of these large-scale zemstvo plans potentially required a long period of time. The comparative analysis carried out by the authors on the organization of medicine in the Perm province in 1861 and 1914 showed an approximately threefold increase in the network of medical sites with a population growth of 75 %. As a result, by the beginning of the First World War, only half of its residents were provided with affordable basic medical care. The need for a new significant increase in the number of medical sites naturally contributed to the expansion of the boundaries of the payment of zemstvo medicine. The simultan e-ous implementation of the two key zemstvo principles of accessibility and free medical care was reasonably presented to competent contemporaries as a "matter of the distant future."