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

Overview of presentation Background to SHA Development Joint OECD-Eurostat-WHO Health Accounts (SHA) Data Collection Dissemination of SHA data at OECD Methodological development

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

THE 2006 JOINT OECD-EUROSTAT-WHO HEALTH ACCOUNTS (SHA) DATA COLLECTION Development and Evaluation

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

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

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

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

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

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

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

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

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)

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

Standard SHA Tables by country

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

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

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

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)

Preliminary data from Belgian SHA included in OECD Health Data 2006

The System of Health Accounts Methodological Development

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

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

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

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

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

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]

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

Thank you! Sandra.Hopkins@oecd.org Eva.Orosz@oecd.org David.Morgan@oecd.org Roberto.Astolfi@oecd.org www.oecd.org/health/sha