1 The SHA and health accounts data collection David Morgan OECD Health Division Systems of Health Accounting: Belgian Experience in an International Perspective.

1

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

2

Overview of presentation

Background to SHA Development

Joint OECD-Eurostat-WHO Health Accounts (SHA) Data Collection

Dissemination of SHA data at OECD

Methodological development

3

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

4

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

5

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

6

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

7

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)

8

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

9

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

10

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

12

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

13

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

14

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?

16

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

17

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

19

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

22

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

26

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

31

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.

34

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

36

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

37

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

38

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

39

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

40

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