Transcript Proposals for future work on health data and indictors at OECD

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
1
Overview of presentation

Background to SHA Development

Joint OECD-Eurostat-WHO Health Accounts (SHA) Data
Collection

Dissemination of SHA data at OECD

Methodological development
2
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
3
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
4
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
5
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
6
First results of comparative analysis of SHAbased 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)
7
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
8
SHA provides in-depth information on the
multi-functionality of hospitals
The study shows:

Hospital expenditure is not appropriate ‘proxy’ for inpatient 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
9
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 multifunctional 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
10
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
11
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
12
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
13
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*
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
*/partial reporting of HC
14
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
15
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
16
THE 2006 JOINT OECD-EUROSTAT-WHO
HEALTH ACCOUNTS (SHA) DATA COLLECTION

Development and Evaluation
17
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
18
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
19
Dimensions of expenditure in the Joint
Questionnaire
Source
of funding
Financing schemes/
agents
Service providers
Functions
Human Resources
20
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
21
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
22
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
23
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
24
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
25
OECD dissemination of SHA data




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Health Accounts database via internet with access only
through authorisation
Health Accounts tables (country specific and comparative)
via A System of Health Accounts: Implementation webpage
Short country-specific notes (Country-profiles) via webpage
Comparative analysis (OECD Health Working Papers)
Country-specific analysis (OECD Health Technical
Papers)
26
SHA – Implementation in OECD Countries
www.oecd.org/health/sha
27
Standard SHA Tables by country
Country Australia
Year 2004
Unit PARTOT: % total expenditure on health
Provider HPTOT: Total expenditure HP.1-HP.9
Financing Source FSTOT: Total expenditure FS.1-FS.3
Human Resources RCTOT: Total human resources
HF1:
HF1: General
General
government
HF11:
HF12:
governmen General
Social
t
governmen security
t (excl.
funds
Financing Agent
social
security) =
Territorial
governmen
t
HF2:
Private
sector
HF2: Private sector
HF21HF22:
Private
insurance
HFTOT:
Total
HF23:
HF24: NonHF25:
Private
profit
Corporation expenditur
e HF.1households institutions
s (other
HF.3
out-ofserving
than health
pocket exp. households insurance)
Function
HC1HC2: Services of curative and rehabilitative care
43.8
43.8
..
17.6
5.5
8.8
0.0
3.3
61.4
HC1HC2: Services of curative and
rehabilitative care
23.6
23.6
..
7.8
4.3
1.9
0.0
1.6
31.4
0.0
0.0
..
0.0
0.0
0.0
0.0
0.0
0.0
20.2
20.2
..
9.8
1.2
6.9
0.0
1.7
30.0
HC11HC21: In-patient curative and
rehabilitative care
HC12HC22: Day cases of curative
and rehabilitative care
HC13HC23: Out-patient curative
and rehabilitative care
HC14HC24: Services of curative
home and rehabilitative home care
..
..
..
0.0
0.0
0.0
0.0
0.0
0.0
HC3: Services of long-term nursing care
5.6
5.6
..
1.4
0.0
1.4
0.0
0.0
7.1
HC4: Ancillary services to health care
4.2
4.2
..
1.0
0.1
0.8
0.0
0.1
5.2
HC5: Medical goods dispensed to out-patients
8.0
8.0
..
9.5
0.3
9.0
0.0
0.1
17.5
HC5: Medical goods dispensed to
out-patients
7.6
7.6
..
5.6
0.1
5.5
0.0
0.1
13.3
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
HC51: Pharmaceutical and other
medical non-durables
HC52: Therapeutic appliances and
other medical durables
HC6: Prevention and public health services
HC7: Health administration and health insurance
HC9: Not specified by kind
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
data extracted on 2007/01/19 11:35 from OECD.Stat
28
Comparative Tables/Charts (1)
Total Health Expenditure as share of GDP, 2003 and 2004
12.0
10.0
8.0
6.0
4.0
2.0
0.0
Switzerland
Germany
France
Norway
Canada
2003
11.5
10.8
10.4
10.1
9.9
2004
11.6
10.6
10.5
Portugal
Australia
Netherlands
Spain
Japan
Luxembourg
Czech
Republic
Poland
Korea
9.8
9.2
9.1
7.9
7.8
7.7
7.5
6.5
5.5
10.1
9.6
9.2
8.1
8.0
7.3
6.5
5.6
Source: 2006 Joint OECD-Eurostat-WHO Health Accounts (SHA) Data Collection
29
Comparative Tables/Charts (2)
Total Health Expenditure by ICHA-HC Healthcare Function, 2003
HC1HC2: Services of curative and rehabilitative care
HC4: Ancillary services to health care
HC6: Prevention and public health services
HC9: Not specified by kind
HC3: Services of long-term nursing care
HC5: Medical goods dispensed to out-patients
HC7: Health administration and health insurance
HCR1: Capital formation of health care provider institutions
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
Source: 2006 Joint OECD-Eurostat-WHO Health Accounts (SHA) Data Collection
Switzerland
Spain
Portugal
Poland
Norway
Netherlands
Luxembourg
Korea
Japan
Germany
France
Czech Republic
Canada
Australia
0%
30
Comparative Tables/Charts (3)
Current Health Expenditure by ICHA-HP Healthcare Provider, 2003
HP1: Hospitals
HP3: Providers of ambulatory health care
HP5: Provision and administration of public health programs
HP7: Other industries (rest of the economy)
HP2: Nursing and residential care facilities
HP4: Retail sale and other providers of medical goods
HP6: General health administration and insurance
HP9: Rest of the world
100%
80%
60%
40%
20%
Source: 2006 Joint OECD-Eurostat-WHO Health Accounts (SHA) Data Collection
Switzerland
Spain
Portugal
Poland
Norway
Netherlands
Luxembourg
Korea
Japan
Germany
France
Czech Republic
Canada
Australia
0%
31
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)
32
1000
0
3044
3043
3041
Belgium 1
Germany
Netherlands
2094
2083
Spain
New Zealand
662
580
Turkey
777
Slovak Republic 1
Mexico
805
Poland
1149
1276
Hungary
Korea
1361
Czech Republic
1824
2162
Greece
Portugal
2235
2467
Italy
Finland
2508
United Kingdom
2249
2560
OECD average
Japan 1
2596
2825
3120
Australia
Sweden
3124
Austria
2881
3159
France
Ireland
1. 2003
Source: OECD Health Data 2006 , Oct. 2006.
Denmark
3165
Canada
Iceland
3966
2000
Norway
3000
4077
3331
4000
Switzerland
Luxembourg
United States
5089
6102
Preliminary data from Belgian SHA included
in OECD Health Data 2006
7000
6000
5000
33
The System of Health Accounts

Methodological Development
34
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
35
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
36
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
37
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
38
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
39
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]
40
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
41
Thank you!

[email protected]
[email protected]
[email protected]
[email protected]

www.oecd.org/health/sha

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