1 the sha and health accounts data collection david morgan oecd health division systems of health...
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The SHA and health accounts data collection
David Morgan
OECD Health Division
Systems of Health Accounting:
Belgian Experience in an International Perspective
Take-off Seminar for a Research Project
Brussels, 12/03/07
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Overview of presentation
Background to SHA Development
Joint OECD-Eurostat-WHO Health Accounts (SHA) Data Collection
Dissemination of SHA data at OECD
Methodological development
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Why has A System of Health Accounts (SHA) been developed?
OECD has built up, over 20 years, the leading international database on health care systems’ financing and delivery - based on collaboration with national data correspondents
Until 2000, however, OECD Health Data presented health expenditure data reported by member countries according to their national practice
To improve availability and comparability of health expenditure data, OECD Ad Hoc Meeting of Experts in Health Statistics (May 1996) advised to develop an international standard for health care expenditure and financing
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Main problems hindering comparability of pre-SHA health expenditure statistics
Differences in boundaries of health sector limit the comparability of total health expenditure
Institutional (provider) structure (in itself) is not suitable for comparison across countries
From a national health policy perspective: data on spending by provider do not provide adequate information about changes in utilisation of resources
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Basic features of the System of Health Accounts
International statistical standard (an integrated system of comprehensive and internationally comparable accounts and basic accounting rules)
Functional definition of health care goods and services
ICHA (1.0): International Classification for Health Accounting:– Functions of health care services and goods (ICHA-HC)– Categories of providers (health care industries) (ICHA-HP)– Sources of funding (financing agents) (ICHA-HF)
Standard SHA tables cross-classify expenditures under the three basic dimensions
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Major requirements for applying the SHA boundaries
The functional classification of health care (ICHA-HC) is applied in an internationally harmonised way (e.g., LTC)
Expenditure by all the financing agents defined by the SHA is accounted for (e.g., HF.2.4; HF.2.5)
All primary and secondary providers of health care are included (HP.7)
Foreign trade of health services is estimated (HP.9)
Common methods for valuation of health services are applied following the SHA framework
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First results of comparative analysis of SHA-based National Health Accounts
– Eva Orosz and David Morgan: SHA-based National Health Accounts in Thirteen OECD Countries: A Comparative Analysis, OECD Health Working Papers No 16, OECD, 2004 (HWP No. 16)
– Country Studies: OECD Health Technical Papers No. 1 to 13 SHA-based National Health Accounts in Thirteen OECD Countries: Country Studies (HTP)
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SHA provides a more in-depth picture of the role of public and private spending on health care
The fact that the whole health care system is primarily publicly financed does not entail that public financing plays the dominant role in every area.
In only four of the thirteen countries covered in the OECD HWP No.16, namely Denmark, Germany, Japan and Spain, does the public sector play a dominant role in all three main areas
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SHA provides in-depth information on the multi-functionality of hospitals
The study shows:
Hospital expenditure is not appropriate ‘proxy’ for in-patient care
Considerable variation in the share of in-patient curative-rehabilitative care in hospital expenditure
Hospitals provide Long-term care to a varying degree across countries
Different roles of hospitals providing out-patient care
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Major challenges in applying ICHA-HC
Defining more precisely the boundary between health and social care
Defining more precisely the boundary between health and health related functions (e.g., education, research, environmental health, etc.)
Separating health, health-related and non-health activities in the case of complex institutions
Applying functional classification in the case of multi-functional health care organisations (e.g., inpatient care, day care, outpatient care within hospitals)
Treatment of ancillary services (laboratories, diagnostic centres) provided in complex health care organisations
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Major challenges in implementing ICHA-HF
Estimating private expenditure
– Data on private sector expenditure (private insurance, NGOs, corporations) far from complete.
– Household surveys tend to underestimate private health spending
– Household surveys only provide less detailed functional distribution than is needed by the SHA
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Major challenges in applying ICHA-HP
To estimate the expenditure on health care activities by complex institutions that perform health, health-related and non-health activities at the same time: – Nursing and residential-care facilities (HP.2) may provide:
HC.3; HC.2; HC.R.6.1, HC.R.6.9; and non-health services
– Public health authorities (HP.5) may provide: HC.6; HC.R.4; HC.R.5; etc.
– Medical universities may provide: HC.1&HC.2; HC.R.2, HC.R.3
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Growing expectations for implementation and further development of the SHA
What information can/should SHA-based health accounts provide for policy-makers?
Factors that drive growth in health spending
Differences across countries in expenditure growth and composition of expenditure
Monitor the effects of particular health reform measures over time
How services are utilised by regional and social groups in the population
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Status of SHA implementation in OECD countries as of October 2006
Data have been (or will be) provided to the 2006 Joint Health Accounts data collection
Intention to report data for the 2007 Joint Health Accounts data collection
Data not expected for the 2007 data collection
Australia, Belgium, Canada, Czech Republic, France, Germany, Japan, Korea, Luxembourg, Netherlands, Norway, Poland, Portugal, Slovak Republic, Spain, Switzerland, United States*
*/partial reporting of HC
Austria, Denmark, Finland, Iceland, Hungary, Turkey.
SHA implementation planned or currently underway:
Greece, Ireland, Italy,
New Zealand, Sweden,
Break in SHA implementation:
Mexico, United Kingdom
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Implementation of the SHA (i.e., a new system) requires
– Political commitment– Clear institutional responsibility with additional human
resources– Changes in statistical approach
– Changes in data processing (and often in data gathering)
– Co-operation among several organisations
Why SHA implementation has proved slower than envisaged?
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SHA activity at OECD
2000 – publication of A System of Health Accounts 2000-2003 – SHA tables collected on an occasional basis
for presentation at the annual experts meeting 2004 - Working Paper and 13 Technical Papers published 2005 SHA pilot SHA data collection (SHA tables received
from 10 OECD countries 2005 – agreement on joint OECD-EUROSTAT-WHO SHA
questionnaire for 2006 collection
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THE 2006 JOINT OECD-EUROSTAT-WHO HEALTH ACCOUNTS (SHA) DATA COLLECTION
Development and Evaluation
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Purposes of the joint SHA data collection
The most important goal is to reduce the burden of data collection for the national authorities
Increase the use of international standards and definitions
– Further harmonisation across national health accounting practices in order to improve availability and comparability of health expenditure data
Encouraging SHA Implementation
Quality of data depends primarily on contributions by member countries
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Documents of the Questionnaire
Summary of the Practical working arrangements for co-operation between OECD, EUROSTAT and WHO
Questionnaire to be completed:– Tables– Methodology
Technical notes– Structure of the classifications and tables– Additional descriptions and definitions used in the Joint
Questionnaire
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Dimensions of expenditure in the Joint Questionnaire
Source of funding
Financing schemes/agents
Human Resources
Service providers Functions
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Methodological information requested
I. Data sources
II. Correspondence tables between health expenditure categories used in national practice and the ICHA
III. Current state of ICHA implementation– Which deviations from ICHA are currently found in the
country’s SHA compilation– Estimation procedures and adjustments
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JHAQ data availability in 2006
21 countries (16 OECD + 5 EU non-OECD) had submitted data:
19 by end-May and 2 additional countries in September
Current expenditure complete at 1-digit level and at 2-digit level:
– complete for HF
– on average two thirds for HC & HP
Few countries provided the new entries: HFxFS, RCxHP (total
spending on pharmaceuticals, human resources, capital
spending by provider), information on public/private ownership
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Main results of the revision process
Considerable improvement of SHA-based data availability:
– 21 (16+5) of 38 OECD and/or EU countries provided data by September
– More detailed SHA tables than before
Several countries have (re-)started the implementation /preparation for SHA implementation
Preliminary analysis suggests improvement in comparability of data
– More standard use of SHA to generate estimates of total health expenditure
– Greater harmonisation in applying ICHA
– However, deviations from ICHA still remain and needs for SHA revision more evident
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Implications for comparative analysis of data
Initial focus on main aggregates and sub-aggregates– Total expenditure on health– Total expenditure on personal care– Total expenditure on collective care– Total current expenditure – Total expenditure capital spending– Total expenditure on health financed by the general
government– Total expenditure on health financed by the social security– Total expenditure on health privately funded – Total expenditure on health through private insurance– Total expenditure on health through OOPS
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Next steps to improve the process
Use of improved tools and more clear indications (tables,
explanatory notes, etc)
Clearer and standard process to review the data
Reduction of the time required in the validation process
– increase of the involved resources in the international
organisations
– improved compliance with the schedule
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OECD dissemination of SHA data
Health Accounts database via internet with access only through authorisation
Health Accounts tables (country specific and comparative) via A System of Health Accounts: Implementation web-page
Short country-specific notes (Country-profiles) via web-page
Comparative analysis (OECD Health Working Papers) Country-specific analysis (OECD Health Technical
Papers)
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SHA – Implementation in OECD Countrieswww.oecd.org/health/sha
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Standard SHA Tables by country
HF11: General
government (excl. social
security) = Territorial
government
HF12: Social
security funds
HF21-HF22: Private
insurance
HF23: Private
households out-of-
pocket exp.
HF24: Non-profit
institutions serving
households
HF25: Corporation
s (other than health insurance)
43.8 43.8 .. 17.6 5.5 8.8 0.0 3.3 61.4
HC11HC21: In-patient curative and rehabilitative care 23.6 23.6 .. 7.8 4.3 1.9 0.0 1.6 31.4
HC12HC22: Day cases of curative and rehabilitative care 0.0 0.0 .. 0.0 0.0 0.0 0.0 0.0 0.0
HC13HC23: Out-patient curative and rehabilitative care 20.2 20.2 .. 9.8 1.2 6.9 0.0 1.7 30.0
HC14HC24: Services of curative home and rehabilitative home care
.. .. .. 0.0 0.0 0.0 0.0 0.0 0.0
5.6 5.6 .. 1.4 0.0 1.4 0.0 0.0 7.1
4.2 4.2 .. 1.0 0.1 0.8 0.0 0.1 5.2
8.0 8.0 .. 9.5 0.3 9.0 0.0 0.1 17.5
HC51: Pharmaceutical and other medical non-durables 7.6 7.6 .. 5.6 0.1 5.5 0.0 0.1 13.3
HC52: Therapeutic appliances and other medical durables 0.4 0.4 .. 3.8 0.3 3.5 0.0 0.0 4.2
1.4 1.4 .. 0.1 0.0 0.1 0.0 0.0 1.5
2.1 2.1 .. 0.7 0.7 0.0 0.0 0.0 2.8
.. .. .. .. .. .. .. .. 0.0
65.1 65.1 .. 30.3 6.7 20.1 0.0 3.6 95.4
2.3 2.3 .. 2.3 0.0 0.0 0.0 2.3 4.6
67.5 67.5 .. 32.5 6.7 20.1 0.0 5.8 100.0
data extracted on 2007/01/19 11:35 from OECD.Stat
HCTOT: Total current expenditure HC.1-HC.9
HCR1: Capital formation of health care provider institutions
HCTOTHCR1: Total expenditure HC.1-HC.9; HC.R.1
HC5: Medical goods dispensed to out-patients
HC6: Prevention and public health services
HC7: Health administration and health insurance
HC9: Not specified by kind
HC1HC2: Services of curative and rehabilitative care
HC3: Services of long-term nursing care
HC4: Ancillary services to health care
HC5: Medical goods dispensed to out-patients
HF2: Private sector HFTOT: Total
expenditure HF.1-
HF.3
Function
HC1HC2: Services of curative and rehabilitative care
Financing Agent
HF1: General
government
HF1: General government
HF2: Private sector
Financing Source FSTOT: Total expenditure FS.1-FS.3
Human Resources RCTOT: Total human resources
Unit PARTOT: % total expenditure on health
Provider HPTOT: Total expenditure HP.1-HP.9
Country Australia
Year 2004
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Comparative Tables/Charts (1)
Total Health Expenditure as share of GDP, 2003 and 2004
0.0
2.0
4.0
6.0
8.0
10.0
12.0
2003 11.5 10.8 10.4 10.1 9.9 9.8 9.2 9.1 7.9 7.8 7.7 7.5 6.5 5.5
2004 11.6 10.6 10.5 10.1 9.6 9.2 8.1 8.0 7.3 6.5 5.6
Switzerland Germany France Norway Canada Portugal Australia Netherlands Spain Japan LuxembourgCzech
RepublicPoland Korea
Source: 2006 Joint OECD-Eurostat-WHO Health Accounts (SHA) Data Collection
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Comparative Tables/Charts (2)
Total Health Expenditure by ICHA-HC Healthcare Function, 2003
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Au
stra
lia
Ca
na
da
Cze
ch R
ep
ub
lic
Fra
nce
Ge
rma
ny
Jap
an
Ko
rea
Lu
xem
bo
urg
Ne
the
rla
nd
s
No
rwa
y
Po
lan
d
Po
rtu
ga
l
Sp
ain
Sw
itze
rla
nd
HC1HC2: Services of curative and rehabilitative care HC3: Services of long-term nursing care
HC4: Ancillary services to health care HC5: Medical goods dispensed to out-patients
HC6: Prevention and public health services HC7: Health administration and health insurance
HC9: Not specified by kind HCR1: Capital formation of health care provider institutions
Source: 2006 Joint OECD-Eurostat-WHO Health Accounts (SHA) Data Collection
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Comparative Tables/Charts (3)
Current Health Expenditure by ICHA-HP Healthcare Provider, 2003
0%
20%
40%
60%
80%
100%
Au
stra
lia
Ca
na
da
Cze
ch R
ep
ub
lic
Fra
nce
Ge
rma
ny
Jap
an
Ko
rea
Lu
xem
bo
urg
Ne
ther
lan
ds
No
rwa
y
Po
lan
d
Po
rtu
ga
l
Sp
ain
Sw
itze
rla
nd
HP1: Hospitals HP2: Nursing and residential care facilities
HP3: Providers of ambulatory health care HP4: Retail sale and other providers of medical goods
HP5: Provision and administration of public health programs HP6: General health administration and insurance
HP7: Other industries (rest of the economy) HP9: Rest of the world
Source: 2006 Joint OECD-Eurostat-WHO Health Accounts (SHA) Data Collection
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Link between SHA and OECD Health Data
OECD Health Data is the main dissemination product of Financial and non-financial data from OECD Health Division
Collection runs concurrently with Joint SHA Collection with overlapping networks
Data from Joint Collection compatible with OECD Health Data (and Health at a Glance)
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Preliminary data from Belgian SHA included in OECD Health Data 2006
6102
5089
4077
3966
3331
3165
3159
3043
3041
2881
2825
2596
2508
2467
2249
2235
2162
2094
2083
1824
1361
1276
1149
805
777
662
580
3044
2560
3124
3120
0
1000
2000
3000
4000
5000
6000
7000
Uni
ted
Sta
tes
Luxe
mbo
urg
Sw
itzer
land
Nor
way
Icel
and
Can
ada
Fra
nce
Aus
tria
Aus
tral
ia
Bel
gium
1
Ger
man
y
Net
herla
nds
Den
mar
k
Sw
eden
Irel
and
OE
CD
ave
rage
Uni
ted
Kin
gdom Ita
ly
Japa
n 1
Fin
land
Gre
ece
Spa
in
New
Zea
land
Por
tuga
l
Cze
ch R
epu
blic
Hun
gary
Kor
ea
Pol
and
Slo
vak
Rep
ublic
1
Mex
ico
Tur
key
1. 2003Source: OECD Health Data 2006 , Oct. 2006.
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The System of Health Accounts
Methodological Development
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General aims of Health Accounting developmental work
The basic methodological framework of SHA has become widely accepted
On the other hand: The SHA Manual and the International Classification for
Health Accounts (ICHA) require some refinement and further extension
– to improve comparability of health expenditure
– to better contribute to the evaluation of health systems performance
– to better present the importance of health sector within the national economy
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SHA developmental work in 2007-2008 OECD Draft Programme of Work on Health
Second edition of the SHA Manual is expected to better fulfil the requirements of international comparability and to enhance the analytical power of the SHA, through a
a refined conceptual framework;
a revised version of the International Classification for Health Accounts
improved methods and more detailed guidance
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Key issues to be addressed
Main factors limiting international comparability:
Differences in boundaries of the health sector (e.g., in definition of Long-term care)
Differences in applying the functional classification (e.g., separation of inpatient care, day care, outpatient care within hospitals)
Lack of reliable price indices in national statistics.
– For international comparison, health expenditure are deflated by economy-wide (GDP) price indices
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Key issues to be addressed (cont.)
Lack of reliable health-specific Purchasing Power Parities (PPPs)
– economy-wide PPPs are used
The current categories of health care financing (ICHA-HF) do not enable an adequate reflection of the complex and changing systems of health financing
Reliability and comparability of private expenditure requires improvement
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Key issues to be addressed (cont.)
The SHA Manual 1.0 does not provide guidance to estimate expenditure by age and gender groups, and disease categories
The SHA Manual does not distinguish appropriately between the production and the final consumption of health services
Review of 2- and 3-digit categories from the point of view of international comparability and policy relevance
Experts in member countries will be invited to propose further issues for consideration
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Main components of SHA developmental work in 2007-2008
Refinement of ICHA, including Guidelines for LTC
Estimating Expenditure by Disease, Age and Gender under the System of Health Accounts (SHA) Framework
Refinement of the SHA framework for health financing [HA(2006)7]
Improving the comparability and availability of private health expenditure
Development of reliable health-specific Purchasing Power Parities (PPPs)
Incorporating Input, Output and Productivity Measurement into the SHA Framework
Strengthening the connection between the SHA and the SNA [HA(2006)6]
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Involvement of national experts is indispensable
A wider circle of experts will be invited to participate in reviewing particular chapters of SHA 1.0
Ad hoc meetings
The Meetings of Health Accounts Experts is considered as the main professional forum to discuss interim reports and drafts
SHA Electronic Discussion Group (SHA EDG) is expected to facilitate discussions in a wider circle
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Thank you!
[email protected] [email protected] [email protected] [email protected]
www.oecd.org/health/sha