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

11. 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

15. Why SHA implementation has proved slower than envisaged?
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

16. SHA activity at OECD 2000 – publication of A System of Health Accounts
– SHA tables collected on an occasional basis for presentation at the annual experts meeting
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

18. 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

20. Dimensions of expenditure in the Joint Questionnaire
Source
of funding
Financing schemes/
agents
Service providers
Functions
Human Resources

21. 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

23. 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

24. 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

25. 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)

27. SHA – Implementation in OECD Countries www.oecd.org/health/sha

28. Standard SHA Tables by country

29. Comparative Tables/Charts (1)
Source: 2006 Joint OECD-Eurostat-WHO Health Accounts (SHA) Data Collection

30. Comparative Tables/Charts (2)
Source: 2006 Joint OECD-Eurostat-WHO Health Accounts (SHA) Data Collection

31. Comparative Tables/Charts (3)
Source: 2006 Joint OECD-Eurostat-WHO Health Accounts (SHA) Data Collection

32. 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)

33. Preliminary data from Belgian SHA included in OECD Health Data 2006

34. The System of Health Accounts
Methodological Development

35. 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]

41. 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

42. Thank you! Sandra.Hopkins@oecd.org Eva.Orosz@oecd.org