10.9 Health accounts#
10.9.1 System of Health Accounts#
Health care systems in all countries continue to evolve in response to changing demographics and disease patterns, rapid technological advances and more and more complex financing and delivery mechanisms. Common goals are equity, efficiency and effectiveness of care. A health account (HA) facilitates their achievement by reporting health expenditures using the current global standard, the System of Health Accounts (SHA 2011), which ensures a systematic description of the financial flows related to health care goods and services. The aim of SHA 2011 is to describe the health care system from an expenditure perspective both for international and national purposes. The standard was prepared by the International Health Accounts Team (IHAT), comprising the health accounts experts from three organizations: OECD, WHO and Eurostat. It is jointly maintained by these organizations.
SHA 2011 provides a systematic description of the financial flows related to the consumption of health care goods and services. It sets out the boundaries, definitions and concepts of comparative health accounting. It enables tracking of all health spending including expenditures on health promotion, prevention, treatment, rehabilitation, palliative care and related ancillary, administration and governance services as well as provision of medical goods for residents of a given country over a defined period of time regardless of the entity or institution that financed and managed that spending.
SHA 2011 can be used as a monitoring and evaluation tool to track changes in policy priorities and to determine whether the introduction of reforms and new programs has resulted in changes in health resources allocation and expenditure.
The core tables in SHA 2011 address the following three basic aspects (and corresponding questions):
the types of goods that are purchased and the kinds of services that are performed (what kinds of health care goods and services are consumed?);
the sources of funding, the financing scheme(s) that pay(s) for these goods and services (where does the money come from?); and
the providers that deliver health care goods and services (where does the money go?).
The ultimate goal of data compilation of the core accounts is to answer these three questions with respect to each transaction that incurs health care expenditure. Thus, the SHA 2011 is organized around a triaxial system for the health expenditure recording. It incorporates the International Classification for Health Accounts (ICHA), which defines:
consumption: health care by function (ICHA-HC), and related classifications;
financing: financing schemes of health care (ICHA-HF), and related classifications;
provision: health care service provider industries (ICHA-HP), and related classifications.
The entire mapping of health care system and its complex funding is a multi-dimensional process. Therefore, these three core classifications are complemented by additional classifications generally used in producing a health account, such as
Revenues of health care financing schemes (ICHA-FS);
Institutional units providing revenues of financing schemes (FS.RI);
Financial Agents (ICHA-FA);
Factors of health care provision (ICHA-FP);
Diseases and conditions (DIS).
SHA 2011 distinguishes between the two indicators current health expenditure and capital health expenditure (ICHA-HK). Principles and classification for capital expenditures are borrowed from international standard, the 2008 SNA.
Existing national and international classifications, such as the International Standard Industrial Classification of All Economic Activities (ISIC), served as a starting point in defining the ICHA. WHO led a discussion on the updated version of COICOP 2018 in order to facilitate linkage to SHA2011. Disease and condition classification have a strong linkage with the International Classification of Diseases (ICD).
10.9.2 General guidelines and tools#
The World Health Organization (WHO) is the international organization with primary responsibility for the Health accounts country platform (🔗). Through this platform (further described below), WHO provides countries with an accounting framework, guidelines, tools and technical support to institutionalize and set up a harmonized, integrated platform for timely collection of health expenditure data.
WHO has a mandate for health expenditure data at global level, as per the World Health Assembly (WHA) to establish and strengthen institutional capacity in order to generate country-level evidence and effective, evidence-based policy decision-making on the design of universal health coverage systems, including tracking the flows of health expenditures through the application of standard accounting frameworks.
Health in All Policies: Framework for Country Action
While the Health in All Policies (HIAP) Framework concerns health policy and not statistics per se, it provides the background within which health statistics are being developed and implemented.
The Framework provides countries with a practical means of achieving a coherent policy approach to health, particularly at the national level. It presents an approach to health-related rights and obligations. It improves the accountability of policymakers for health impacts at all levels of policymaking. It includes an emphasis on the consequences of public policies on health systems and determinants of health and well-being. It also contributes to sustainable development. It can also be adapted for supranational level decision-making as well as at the local level. This is important as decentralisation of government functions has empowered local authorities in many areas.
In terms of take-up, as of mid-2020, some countries have already adopted a HIAP based approach, even though this may not be obvious. In other countries, the framework has yet to be operationalized.
Health Accounts Production Tool (HAPT)
For reducing the need for technical assistance, increasing local capacity and efficiency for health account production, the Health Accounts Production Tool (HAPT) was developed with input from the WHO and the World Bank. The tool is maintained by WHO and distributed free of charge. It guides health accounts’ teams through the entire production process. Its key features are:
step-by-step directions to help guide country teams through the health accounts estimation process;
platform to manage complex data sets, reducing issues with missing data;
survey creator and import function to streamline data collection and analysis;
built-in auditing feature to facilitate review and correction of double-counting of expenditures;
automation of the mapping of data;
interactive diagram to help analysts visualize the flow of funding through the health sector; and
automatically-generated health accounts tables and reports.
HAPT is a data management tool that has been developed for low- and middle-income countries for the development of health accounts in the standardised format of SHA 2011. HAPT is used in more than 60 countries around the world.
Health Accounts Analysis Tool (HAAT)
The Health Accounts Analysis Tool (HAAT) was developed and is maintained by the WHO. It guides health accounts teams through the analysis of health expenditure data by automatically producing relevant graphs and charts using the data entered into the HAPT. In 2021, after complex development, HAPT and HAAT will be combined in one common tool under the HAPT name. In addition, SHA 2011 is accompanied by several supportive documents produced by OECD, WHO and Eurostat. Each document aims to promote consistency of approach across countries in implementing SHA 2011. The key documents are summarised below:
Pilot exercises of SHA 2011: Lessons learned, (OECD, 2014)
During the latter stages of the process of revising SHA 1.0 to create SHA 2011, pilot testing of a preliminary draft of the new manual was conducted in a Member State of each WHO region and in a selection of OECD countries. The aim was to provide feedback and information on the appropriateness of the revised classifications and the overall feasibility of the new system. Participating countries were asked to test the various draft classifications of the new manual in different stages of development. The pilot testing results were used to refine the revision process.
This report Pilot exercises of SHA 2011: Lessons learned (🔗) provides a summary of the main lessons learned, consolidating the reports of the pilot countries together with exchanges with other countries. The inventory of problems found by the pilot teams, the solutions proposed, and the usefulness of the revised proposals for policy were discussed when clarification on selected subjects was required. The cross-classifications of the data provided were analysed for their internal and cross-classification consistency.
Indicator metadata registry (IMR), WHO
The Indicator metadata registry (IMR) is a central source of metadata of health-related indicators used by WHO and other organizations. It includes indicator definitions, data sources, methods of estimation and other information that allow users to get a better understanding of their indicators of interest. It facilitates complete and well-structured indicator metadata, harmonization and management of indicator definitions and code lists, internet access to indicator definitions, and consistency with other statistical domains. It promotes interoperability through the SDMX-HD indicator exchange format and allows the incorporation of appropriate international standards such as SDMX Metadata Common Vocabulary (MCV), the ISO 11179 Metadata Registry, Data Documentation Initiative (DDI) and Dublin Core (DCMES).
10.9.3 Guidelines and tools dealing with specific issues#
Accounting and mapping of long-term care expenditure under SHA 2011, (2012, OECD)
Accounting for long-term care (LTC) under the SHA framework is one of the major issues affecting the overall comparability and usefulness of international health expenditure data. In the past, comparability of long-term care and, therefore, total health care expenditure figures were limited since the previous version of the SHA (SHA 1.0) allowed for multiple interpretations of the LTC definition and boundary. Much variance was thus triggered by the different national notions of LTC, for example, which ministry had responsibility for LTC or how LTC was financed.
Annex 1 of the document, entitled Additional guidance on LTC services provides examples of services with recommended accounting practices complementing the corresponding LTC paragraphs in SHA 2011.
Guidelines to measure expenditure on over-the-counter (OTC) drugs, (2012, OECD)
Drawing on current practices, the OECD Guidelines to measure expenditure on over-the-counter (OTC) drugs (🔗) aim to assist countries in starting to report OTC drug expenditures, as well as helping others to improve their current methodology. Moreover, the Guidelines seek to enhance the exchange of experiences between countries so that the comparability, accuracy, reliability and policy relevance of pharmaceutical expenditure data can be improved.
The Guidelines describe a general approach, consisting of four areas:
National legislation;
Data sources;
Mapping into the SHA categories; and
Adjustments to the data.
These are complemented with further clarifications on the new definitions of OTC drugs presented in SHA 2011 together with information on how to capture recent developments in the OTC drug market, such as the intensification of patient mobility across borders and the diffusion of on-line purchases.
Implementing the capital account in SHA 2011, (2012, OECD)
Reflecting the distinct treatment of current and capital spending and in an effort to avoid some of the previous ambiguities surrounding capital spending, the SHA 2011 introduced a new separate chapter on the accounting of capital formation in health systems. The aim of the chapter - Implementing the capital account in SHA 2011 (🔗) - is to provide a clearer definition of the aggregate capital formation in health care systems, while proposing a new for SHA breakdown of capital formation by the type of assets (i.e., infrastructure, machinery, etc.). Furthermore, a capital account has been developed in the chapter to allow the reporting not only of total expenditure on capital formation but also what sources have been used to fund the purchase of new assets.
In an effort to test the understanding and the feasibility of reporting the various components of the new capital account table, the OECD invited its member countries to participate in a study. Nine countries provided feedback on the various methodologies, data sources they currently use, or could feasibly use, in order to report the various items of the proposed capital account, as well as identifying those parts that they envisage would be problematic in their reporting. In addition to the country responses, the OECD investigated various national and international data sources currently available that would allow for additional reporting, and it analysed some aspects of the financing mechanism of capital acquisition, in particular for France and Germany.
Guidelines for the implementation of the SHA 2011 Framework for accounting health care financing, (2013, OECD)
The accounting framework for health care financing is a key component of SHA 2011. It makes health accounts more adaptable to rapidly evolving health financing systems, further enhances cross-country comparability of health expenditures and financing data and leads to improvement of the information base for the analytical use of national health accounts.
The Guidelines for the implementation of the SHA 2011 Framework for accounting health care financing (🔗), provide:
a more detailed explanation of the various concepts, particularly concerning the role of the government in the health sector and foreign aid; practical approaches for preparing SHA data relevant to health care financing, together with possible methodologies that may be useful in the case of complex financing arrangements;
a set of tools that health accountants can choose from, according to their specific needs.
Expenditure on prevention activities under SHA 2011: Supplementary guidance (2013, OECD)
A key criterion for inclusion under SHA 2011 is whether the primary purpose of the spending is health. Therefore, policies that address the wider determinants of health and have known impacts upon health, for example. Improving or increasing incomes, employment, housing, or active travel are considered outside the SHA boundary as they have another primary purpose. However, much of the public spending to improve occupational health and safety and environmental health, to prevent mortality and injuries in road and transport accidents, and to increase food safety, do fall within the boundary of prevention.
The document Expenditure on prevention activities under SHA 2011: Supplementary guidance (🔗) strives to better define the prevention boundaries in three ways: in relation to other health spending, health-related spending, and non-health spending. Thus, the legislative and regulatory process to increase health and safety, or curtail the advertising and promotion of hazardous behaviour, are considered part of health governance rather than spending on prevention per se; while the enforcement of such regulations is classed as health-related spending.
The costs of compliance with regulations by individuals and companies may have the purpose of avoiding the penalties for contravention, so any expenditure in this domain is also outside the boundary of prevention and health. Likewise, voluntary measures by individuals and companies may have a primary purpose other than health, and so are outside the boundary too. When their purpose is prevention, public health programmes and personal preventive healthcare services are within the prevention boundary, including when requested by patients – these include many forms of information, education, counselling and mass communication, plus immunisation, screening and check-ups. Pharmaceutical spending, including prophylactic medication and contraceptives, is classed with medical goods rather than preventive spending under SHA 2011.
Guidelines to Improve Estimates of Expenditure on Health Administration and Health Insurance (🔗);
Guidelines for Improving the Comparability and Availability of Private Health Expenditures (🔗);
Feasibility and Challenges of Reporting Factors of Provision in SHA 2011 (🔗);
Improving Estimates of Exports and Imports of Health Services and Goods (🔗);
10.9.4 Examples of national practice#
The Philippine National Health Accounts (PNHA) is one of the satellite accounts being produced by the Philippine Statistics Authority (PSA). It presents data on the country’s health spending, health financing and health management over a defined period of time. Early compilation of PNHA used local estimation methodologies approved by PSA Board in 2011. The country adopted SHA 2011 in 2016 and officially released PNHA-SHA estimates for 2014 to 2016 in 2017. From then on, PSA annually compiles PNHA-SHA.
The latest release of PNHA-SHA for 2016 to 2018 generated the following tables:
Current Health Expenditures by Revenues of Health Financing Schemes;
Current Health Expenditures by Institutional Units Providing Revenues to Financing Schemes;
Current Health Expenditures by Financing Agent;
Current Health Expenditures by Health Care Financing Scheme;
Current Health Expenditures by Health Care Providers;
Current Health Expenditures by Factors of Health Care Provision;
Health Capital Formation Expenditures;
Current Health Expenditures by Health Care Function;
Current Health Expenditures by Income Quintile Group;
Current Health Expenditures by Disease Group;
Current Health Expenditures by Age and Sex Group;
Current Health Expenditures by Region;
Total Health Expenditures.
10.9.5 Further developments#
The basic aim of the WHO Health Accounts Country Platform (🔗) is to institutionalize a harmonized country platform for annual and timely collection of health expenditure data, with a particular focus on the distribution of expenditure by disease and health functions. It strengthens the capacity of country health account teams to report health expenditures using SHA 2011 and to analyse and produce policy-relevant reports.
Most EU Member States and OECD countries have implemented the SHA 2011 framework. Many WHO Member States are also implementing the SHA 2011 standard or initiating the process. OECD, Eurostat and WHO will continue to support the SHA 2011 implementation by providing training and technical assistance.