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Calculation, paperwork, and medicine, 1500–2000

Accounting is about ‘how much’ and is usually assumed to be about money. It is viewed as a financial technology related to the administration of finances, costing, and the calculation of efficiency. But this book suggests a broader understanding of accounting, linking related perspectives and lines of research that have so far remained surprisingly unconnected: as a set of calculative practices and paper technologies that turn countable objects into manageable units, figures, and numbers that enable subsequent practices of reckoning, calculating, valuing, controlling, justifying, communicating, or researching and that generate and appear in account- or casebooks, ledgers, lists, or tables.

And Accounting for Health involves both money and medicine and raises moral issues, given that making a living from medical treatment has ethical ramifications. Profiting from the ‘pain and suffering of other people’ was as problematic in 1500 as it is in today’s debates about the economisation of medicine and the admissibility of for-profit hospitals. In current debates about economisation of medicine, it is hardly noticed that some versions of these patterns and problems has been with health and medicine for centuries – not only in the modern sense of economic efficiency, but also in a traditional sense of good medical practice and medical accountability.

Spanning a period of five centuries (1500–2011) and various institutional settings of countries in the Western world, Accounting for Health investigates how calculative practices have affected everyday medical knowing, how these practices changed over time, and what effects these changes have had on medicine and medical knowledge.

Hiob Finzel’s Rationarium praxeos medicae, 1565–89
Michael Stolberg

Sixteenth-century physicians were a major group among the rising class of urban professionals whose economic fortunes rested almost entirely on their academic training and their skills. But little is known so far about their financial situation and economic aspects of sixteenth-century medical practice. Michael Stolberg’s chapter will follow these issues by using the example of the German practitioner Hiob Finzel (c. 1526–89). Finzel, a town physician in Weimar and later in Zwickau, left three heavy folio volumes of his practice journal where he recorded for a period of almost twenty-five years more than 10,000 consultations and the fees his patients paid in return for his services. The practice journal, called Rationarium praxeos medicae, functioned foremost as an account-book, recording the fees paid by thousands of patients, but it also offers a wealth of information on Finzel’s diagnostic and therapeutic practices. At the end of each year, Finzel balanced the accounts to sum up his income and, at the same time, to justify his own work before God. Stolberg’s chapter provides a brief sketch of Finzel’s biography, describes the practice journal and the recorded payments in detail, and highlights the striking religious elements and connotations of Finzel’s Rationarium. Finally, Stolberg analyses the economics of Finzel’s practice and of the relative importance of the payments he received from patients of different social and economic status.

in Accounting for health
The workings of an all-female sickness fund, 1898–1931
Helene Castenbrandt

This chapter investigates the characteristics of a successful voluntary sickness fund in early twentieth-century Sweden. The practices of the Seamstresses Sickness and Burial Fund reveal how a working-class organisation functioned in improving the living conditions of its members. When it was first founded in 1898, it was a small all-female and marginal sickness fund, but by the 1930s it had developed into one of the largest in the city of Gothenburg, with good financial reserves. While successfully attracting new members and retaining its old, the fund also proved to be effective in reducing the costs of long-term sickness cases, one of its greatest concerns. Moreover, the social nature of the fund, its emphasis on mutual aid, and its economic decision-making practices, which went beyond mere capital accumulation, holds much of the explanation for the fund’s success. The fund also took part in initiating discussions on maternity benefits and participated actively in the general women’s rights movement, while also playing a part in the male-dominated sickness fund movement at large. Members’ engagement and willingness to remain members was likely reinforced by how the fund in this way gave a voice for working-class women.

in Accounting for health
Theodore M. Porter

The state-supported mental hospitals that sprung up in abundance in Europe and North America from about 1820 became founts of data and statistics. Doctors always insisted that the asylums were medical institutions, and on this basis, they distinguished administrative accounts, denominated in money, from medical tallies of patients. These institutions, however, were seriously expensive, and as they grew, ever more so. Medical administrators could never ignore the relationship of asylum costs to patient outcomes. A few doctors even presented numerical ratios of costs to cures as the ultimate justification for asylum care – though they often added that inadequate or delayed care was disadvantageous even from the standpoint of financial costs alone. Any such calculation depended data routines and conventions of calculations, none of them straightforward. The numbers, in fact, were not always passed by without criticism, especially since the dubious statistics of one institution tended, by comparison, to show others in an unfavourable light. Hence, although these accounts were often presented in reports as routine and unproblematic, and even on occasion as recipes for effortless administration, they were condemned at other moments as groundless or absurd. Such criticism did not owe to any knee-jerk rejection of numbers by doctors. The necessity of statistics in this and other fields of public health was widely acknowledged. The problem was that doctors as well as administrators were almost compelled to look to the accounts for something they could never provide, a numerical basis for fixing the benefits of treatment.

in Accounting for health
The Royal Jennerian Society and vaccine production
Andrea Rusnock

This chapter examines the mutually reinforcing nature of financial and medical accounts in medical charities through a detailed analysis of the Royal Jennerian Society for the Extermination of the Small Pox, established in London in 1803. The Royal Jennerian Society created three types of accounts: financial (revenues and expenses), medical (numbers of individuals vaccinated and of vaccine packets sent to correspondents), and epistemological (a chronological register of names and residences of vaccinated individuals and sources of vaccine). The last type – the vaccination register – introduced an innovative method for reconstructing the lineal descent of a vaccine, and enabled the Royal Jennerian Society to investigate alleged claims of failed vaccinations. The vaccination register marked an important shift in the presentation and use of case histories from narrative prose to enumerated table, the modern constitutive form of medical knowledge.

in Accounting for health
Barry M. Doyle

In the latter part of the nineteenth century, and especially in the first third of the twentieth century, the urban hospital saw its purpose move from the protection and care of patients to their diagnosis and cure. As a result of this process, the numbers and types of patients entering hospitals in England and France, and the funding structures supporting those admitted, underwent a substantial change. These changes were underpinned by new ways of accounting for treatment which saw starkly different approaches adopted by institutions in the two countries. Drawing on evidence from the hospital services of Leeds and Sheffield in England and Lille, Rouen and Le Havre in France, this chapter explores those differences. It utilises a range of sources, including hospital annual reports, financial returns, and internal enquiries, to examine the development of the daily rate – prix de journée – calculated for patient treatment by hospitals in France and the growth of block grants provided by working-class mutual societies in England. It shows that the daily rate, which initially emerged as a way to charge external organisations for using community funded hospitals, became a highly contested site in which accounting practices were deployed to police the boundaries of permissible costs. In contrast, the block grant was adopted, in part, to minimise accounting complexity and administrative costs, but more importantly to shore up the residual charitable elements of the ‘voluntary hospital’ system and impose strict financial discipline. Each of these approaches fed into postwar socialised hospital services, shaping accounting and financial practices for decades to come.

in Accounting for health
Axel C. Hüntelmann

What does the Charité’s cabbage garden have to do with medical knowledge and economy? And how are accounting, economy, and health interconnected beyond current discussions about economisation? Bringing together health, medicine, and accounting, the chapter on hospital economies investigates the Charité hospital’s various economies between 1780s and 1910: its Ökonomie of functional entities, like the kitchen, laundry, brewery; the bodily economy of its sick inmates; and the hospital’s administrative economy that, after 1900, professionalised as ‘hospital economics’. Hüntelmann argues that all of these economies were linked together and that health and accounting have long been deeply entangled with one another. The chapter demonstrates this by focusing on inmates’ food and diet: in the hospital’s Ökonomie, the production and supply of food was registered and balanced against consumption; daily consumption rates and diets were calculated for each person, monetised, and used to derive daily cost-rates and patient fees; annually budgeted and retrospectively balanced. Surveying more than a century, we find that calculative practices and accounting at the Charité hospital were remarkably stable. But there are also major changes over time as the collection of data became more formalised – as the entire process of organising food production, calculating diets, and accounting for food-stocks became more standardised, not least because it involved more people gathering and transforming the necessary dates – and professionalised as ‘hospital economics’. And as the 1780s hospital Ökonomie diminished over time, from the early decades of the twentieth century it mainly existed on paper, interlinked by and represented in the hospital’s accounts.

in Accounting for health
International health accounting in historical perspective, 1925–2011
Christopher Sirrs

In the twenty-first century, the need for countries to reliably measure and compare how much they spend on health is somewhat obvious. By accounting for health expenditure, governments can identify how money flows through their health systems: who funds health care and who provides it, how much money is being spent, and on what. In this way, governments can adjust their priorities, evaluate the impact of interventions, improve health services, and address various structural problems.

The complexity of health systems and methodological problems surrounding national health accounting, however, have undermined attempts to compare health expenditures globally over the last century. This chapter traces the history of international health accounting: organised attempts to measure and compare health spending across national boundaries, including the rules and conventions that ensure the coherence of this information. Although a comprehensive system of health accounts (SHA) has been established only recently, it has had various precursors over the twentieth century. This chapter traces its antecedents through the work of various international organisations, including the League of Nations Health Organisation (LNHO), the United Nations, the International Labour Organisation (ILO), the Organisation for Economic Co-operation and Development (OECD), and the World Bank. In presenting a genealogy of international health accounting, this chapter describes the evolving role the issue of health care financing has played in international health. It also highlights the development of accounting technologies, such as standardised tables and accounting manuals, which have facilitated international measurement and comparison.

in Accounting for health
The case of antidepressants, 1970–90
Jean-Paul Gaudillière
Volker Hess

Three processes – pharmaceutical revolution, drug regulation, and new methodologies – radically changed clinical research after the Second World War. The existing historiography highlights the first two. This chapter addresses the shift in research methodology with special emphasis on accounting. Accounting – understood as tools of knowledge – is thus neither restricted to financial transactions nor to any kind of administrative transactions within enterprises, hospitals, and other health organisations.

This chapter argues for an extended meaning of accounting as the activity of preparing and comparing lists, used in a second step to define different forms of value and construct markets. An invisible bookkeeper has therefore emerged in the world of clinical research who holds together the fields of knowledge and economy. To explore such accounting, the chapter presents the two forms of accounting involved in the research and marketing of Ciba-Geigy’s antidepressants since the 1970s. The first focuses on the accounting technologies that balanced clinical features with the effects of drugs in order to document efficacy and build a hierarchy of uses and putative prescription motives; the second focuses on the market-based accounting involved in scientific marketing that integrates data on sales, prescriptions, and market-shares in order to build a hierarchy of targets and promotional investments.

We therefore propose to understand the blending of clinical research and marketing as the rise of a medico-economic mode of accounting which is bringing together ‘the counter’ and ‘the bedside’ for managing what are massively private, for profit, investments in research and marketing.

in Accounting for health
Abstract only
Axel C. Hüntelmann
Oliver Falk

Accounting is about ‘how much’ and is usually assumed to be about money, the administration of finances and the calculation of efficiency. This introduction suggests a broader understanding of accounting, especially in relation to health, medicine, and medical knowledge; and elaborates its characteristics by using the example of poor boxes in front of hospitals: money going in and out. But donations were made for a certain purpose and laden with moral or social intentions. Therefore, treasurers had to provide information about the donor’s gift to account for its efficient and legitimate use. Accounting for health involved information being collected, listed, and compiled in order to demonstrate good medical practice. Thus, monetary income is correlated with medical outcome. More generally, accounting for health is described as a set of calculative practices and administrative techniques in which money, goods, and other countable objects or patients, detached from their physical materiality, are transformed in specific codes and formats that appear in ledgers, account-books, or tables. Such an expanded meaning of accounting allows to trace the entwined monetary, moral, and epistemic dimensions of accounting (for health) and illuminates the linkage of accounting, health, and medical knowing and its deeply entangled history for over five centuries.

The introduction summarizes the various strains of sociological and historical research and literature on the history of (hospital) accounting and paper technologies. Discussing methodological issues, the introduction elaborates the longue durée perspective and the praxeological approach of the volume’s chapters and gives an overview about the structure of the book.

in Accounting for health