The SHA and health accounts data collection

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.1HC.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
• 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

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 countrys 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 (165) 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 Countrieswww.oecd.or
g/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_at_oecd.org
• Eva.Orosz_at_oecd.org
• David.Morgan_at_oecd.org
• Roberto.Astolfi_at_oecd.org
• www.oecd.org/health/sha