Apples and pears: The role of international health experts in the measurement and comparison of health spending, 1924–2011

In the 21st century, international accounting practices have an important and under-acknowledged role in shaping national understandings of health spending. Rules and conventions set by international organisations help determine how countries measure the flow of money through their health systems, and critically, provide a framework in which they can reliably compare this spending with other countries of interest. Changes in accounting rules can have serious ramifications – for example, in response to recent changes, £21 billion was added to UK health spending in 2016, a jump from 8.7 per cent to 9.9 per cent in relation to GDP.

This paper explores the evolution of attempts by international health experts over the 20th century to measure and compare health spending worldwide. Beginning with the work of the League of Nations Health Organisation (LNHO) in the 1920s, it explores the role played by a multitude of international organisations in developing a systematic accounting framework (the UN, ILO, WHO, OECD, Eurostat and World Bank). It also explores the role played by key individuals and experts, such Brian Abel-Smith, in developing the international basis for comparison. In so doing, the paper seeks to illuminate the crucial political dimension of these various initiatives. This includes concerns about rising consumer demand and the costs of delivering health care, WHO’s focus on health planning in the 1960s, and the focus on equity and efficiency which underscores the current concern with health systems performance.

Outside of health financing circles, little has been written on the historical development of international health accounting. This paper seeks to understand the emergence of a discipline of profound importance for understanding the development of health systems.