History

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.

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.

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 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.

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 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.

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.

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.

Accounts related to private medical practices and held by the practitioners themselves are both a part of medical activity and vehicle of information about healers’ practices and outlooks. This chapter is based on the ledgers written by three healers active in the last decades of the eighteenth century in the Geneva region: a country surgeon, a physician established in a small town, and a physician working in Geneva itself. Each practitioner imagined a structure and a code in order to elaborate and keep information about his practice and payments made. In proceeding thus, he surrenders information relevant to the meaning the accounts had for him and the organisation of his practice. The items listed inform both on the services offered, the value given to them, the expediency of clients to pay, and the different medical strategies adopted. Sometimes bills and accounts are clearly related, elsewhere emphasis is on certain types of clientele and, in one case, accounts aimed to estimate the progression of practice and, ultimately, the physician’s success. Comparing accounting practices carries information on the varying nature of medical services from one practitioner to another, on the value of medical counsel, and the social uses of medicine. Town and country practices are complementary, and practitioners from each environment bill different types of services. Contrasting these account systems enables us to understand how practitioners adapted to the demand and reveals something of the nature of the relationship the practitioner established with his patients and the type of medicine he offered.

J. Andrew Mendelsohn’s chapter focuses on economic, governmental, and medical policies in early modern mining societies in Saxony. Starting with the example of a penny box of German miners’ societies and the in and out of clinking pennies, the weekly payments of miners to the societies’ penny box, and the money’s use for injured or harmed miners suffering from miners diseases, J. Andrew Mendelsohn combines economic history (miners’ societies and sick funds as the earliest form of social insurance) and medical history (expertise on miners’ diseases as the earliest form of occupational health). Accounting, Mendelsohn argues, constituted each in relation to the other.

Mines and mining towns were both an important economic sector and a kind of experimental field for medical observation and knowledge production, amid the background of attempts to govern the laboring body of miners. This was because mining investors, with their public responsibility in miners, had a vested interest in miners living longer and healthier (and thus more productive) lives. In this sense Mendelsohn argues that all-pervasive values and practices of welfare, effective work, and good governance – in both a moral and technical sense – entailed accounting for anything significant happening to the bodies of miners. For this reason, the practice of the official mining physician involved substantial administrative organisation, managerial and medical oversight, and various forms of recordkeeping, especially simple forms of accounting, all within a framework of accountability that was both political and economic.