Health systems performance assessment

The system of health accounts (SHA)



Health systems across the globe are continuing to evolve in response to a multitude of factors, including improvements in medical technology and knowledge, increased information about health and health services and greater access to it, changes in health policy priorities to meet shifting disease and demographic patterns, new organisational methods and more complex financing mechanisms. Health accounts also need to adapt to deal with these developments and to anticipate foreseeable future trends.

Health accounts provide a systematic description of the financial flows related to the consumption of health care goods and services. Their intent is to describe a health system from an expenditure perspective. But as more countries implement and institutionalise health accounts, there are increased expectations from analysts, policy makers and the general public alike for the more sophisticated information that can be gained through the greater volume of health expenditure data now available. Health accounts are increasingly expected to provide inputs (along with other statistical information) into improved analytical tools to monitor and assess health system performance. One high priority is to develop reliable, timely data that is comparable both across countries and over time. This is indispensable for tracking trends in health spending and the factors driving it, which can in turn be used to compare it across countries and to project how it will grow in the future. Health accounts are thus used in two main ways: internationally, where the emphasis is on a selection of internationally comparable expenditure data, and nationally, with more detailed analyses of health care spending and a greater emphasis on comparisons over time. Health accounts are crucial for both of these uses.

The system of health accounts (SHA) shares the goals of the System of National Account (SNA) to constitute an integrated system of comprehensive, internally consistent, and internationally comparable accounts, which should as far as possible be compatible with other aggregated economic and social statistical systems.

The International Classification for Health Accounts (ICHA)

The International Classification for Health Accounts (ICHA) is organized around three axes of the namely, health care function (ICHA-HC), health care provider (ICHA-HP) and health care financing (ICHA-HF), to describe each financial flow in the health care sector. The classification was revisited proposing a more comprehensive structure of classifications: Classification of Revenues of Health Care Financing Schemes (ICHA-FS) and Classification of Factors of Health Care Provision (ICHA-FP). In addition, a number of complementary classifications might be added that are closely linked to one of the three axes like for instance in the area of external trade in health care or capital formation, which are subjects of growing interest for both national and international policy. From an economic perspective, these classifications encompass activities that help to understand the health system in a wider context.

Implementing the System of Health Accounts (SHA)

The formal process of producing the 2011 SHA Manual started in 2007 as a co-operative activity of health accounts experts from the OECD, WHO and Eurostat, known collectively as the International Health Accounts Team (IHAT). The resulting manual has been the subject of an extensive and wide-reaching consultation process aimed at gathering inputs from national experts and other international organisations around the world. It strives to reach a consensus, while also reflecting different perspectives and priorities within the expanding domain of health accounts. In developing the material, great importance has been given to policy relevance, feasibility and sustainability. The Manual is based on the conceptual framework of the System of Health Accounts, but must also address practical possibilities and analytical needs.

The Manual itself draws inspiration from and builds on a number of international manuals and guidelines on health expenditure accounts, most notably: A System of Health Accounts (“SHA 1.0”) (OECD, 2000), the Guide to Producing National Health Accounts (“The Producers Guide”) (WHO, World Bank, USAID, 2003); and the SHA Guidelines (Eurostat/UK ONS, 2003). The wealth of experience gained in implementing these various guidelines around the world, the results of specific health accounting research projects and efforts in international data collections1 have been significant inputs into the Manual’s development.

Data on health expenditure at EU level

Eurostat, the OECD (Organisation for Economic Co-Operation and Development) and the WHO (World Health Organisation) have been cooperating since 2005 to create a common data collection on health expenditure. Main results of this cooperation are the International Classification for Health Accounts (ICHA), the joint manual 'A System of Health Accounts (SHA)', and a Joint Questionnaire on Health expenditure.

Countries submit data according to SHA 1.0 to Eurostat on the basis of a gentlemen's agreement established in the framework of the Eurostat Working Group on "Public Health Statistics". Data collection takes place in agreement with the WHO and the OECD. Common definitions and data specifications are used in the data collection. Annual data covers most of the EU Member States plus Iceland, Norway, Switzerland and some non European countries.

In the meantime, the Commission Regulation (EU) 2015/359 of 4 March 2015 implementing Regulation (EC) No 1338/2008 as regards statistics on healthcare expenditure and financing was adopted paving the way for health care expenditure data collection according to SHA 2011 methodology. The Regulation will first apply for the reference year 2014 and results for the first data collection under the Regulation should be available by the end of 2016. Eurostat already publishes data sets based on SHA 2011 for some countries from 2003 onwards.

The Joint Action (JA) on European Community Health Indicators Monitoring (ECHIM) recommends following these indicators for health care expenditure: