Federal Statistical Office Germany

Department H: Health, Social Statistics, Education, Finance and Taxes; Unit H13: Health Related Accounting Systems

Graurheindorfer Str. 198, D-53117 Bonn

Health care expenditure quantifies the economic resources dedicated to health functions, excluding capital investment. Healthcare expenditure concerns itself primarily with healthcare goods and services that are consumed by resident units, irrespective of where that consumption takes place (it may be in the rest of the world) or who is paying for it. As such, exports of healthcare goods and services (to non-resident units) are excluded, whereas imports of healthcare goods and services for final use are included.
Health care expenditure data provide information on expenditure in the functionally defined area of health distinct by provider category (e.g. hospitals, general practitioners), function category (e.g. services of curative care, rehabilitative care, clinical laboratory, patient transport, prescribed medicines) and financing scheme (e.g. social security, private insurance company, household). For the collection of the data on health care expenditure the System of Health Accounts (SHA) and its related set of International Classification for the Health Accounts (ICHA) is used. SHA sets out an integrated system of comprehensive and internationally comparable accounts and provides a uniform framework of basic accounting rules and a set of standard tables for reporting health expenditure data. The System of Health Accounts - SHA 2011  is a statistical reference manual giving a comprehensive description of the financial flows in health care.

It provides a set of revised classifications of health care functions, providers of health care goods and services and financing schemes. The SHA is currently used as a basis for a joint data collection by OECD, Eurostat and WHO on health care expenditure. The manual sets out in more detail the boundaries, the definitions and the concepts of health accounting – responding to health care systems around the globe with very different organisational and financing arrangements.

Accounting period: Health expenditure and financing data pertain to the calendar year (1 January to 31 December).

Healthcare expenditure is recorded in relation to the international classification for health accounts (ICHA) defining:

• healthcare expenditure by financing schemes (ICHA-HF) — which classifies the types of financing arrangements through which people obtain health services; health care financing schemes include direct payments by households for services and goods and third-party financing arrangements;
• healthcare expenditure by function (ICHA-HC) — which details the split in healthcare expenditure following the purpose of healthcare activities — such as, curative care, rehabilitative care, long-term care, or preventive care;
• healthcare expenditure by provider (ICHA-HP) — which classifies units contributing to the provision of healthcare goods and services — such as hospitals, residential facilities, ambulatory health care services, ancillary services or retailers of medical goods.

1. Household individual consumption on health, including the collective consumption with two exceptions:

1. Occupational health care (intermediate consumption within establishments) minus an estimated share of occupational health in health providers’ and other medical industries net administration;
2. “Remunerated” unpaid household production in the form of transfer payments (social benefits in cash) for home care of sick, disabled and elderly persons provided by family members.

SHA 2011 Manual recommends following the standard System of National Account (SNA) rules for drawing the production boundary of health care services, albeit with two notable exceptions:

• Occupational health care is included in the national totals of health care spending. In SNA, this item is recorded as ancillary services and part of intermediate production of enterprises and
• Part of the cash transfers to private households for care givers of home care for the sick and disabled are treated as the paid household production of health care.

2. Health care financing schemes:

• HF1 - Government schemes and compulsory contributory health care financing schemes;
• HF2 - voluntary health care payment schemes;
• HF3 - Household out-of-pocket payment;
• HF4 - rest of the world financing schemes.

3. NACE rev. 2, section Q, human health and social work activities.

SHA concept is the consumption of health care goods and services.

Health care statistics describe the process of providing and financing health care in countries by referring to health care goods and services, its providers and financing. For the collection of the data on health care expenditure the System of Health Accounts (SHA) and its related set of International Classification for the Health Accounts (ICHA) is used. SHA is a tri-axial system in which the financing, provision and consumption dimensions are covered by the ICHA (International Classification for Health Accounts): Health Care Functions (HC), Health Care Providers (HP), Health Care Financing Schemes (HF).

Data are presented in 3 summary (one-dimensional) tables and 3 cross-classification tables (2-dimensional tables).

Summary tables provide data on:

• Current expenditure by provider (ICHA-HP);
• Current expenditure by function (ICHA-HC);
• Current expenditure by financing scheme (ICHA-HF).

Cross-classification tables refer to:

• HC x HP: Health care expenditure by function and provider: data on which type of health care goods and services are supplied by which health care provider;
• HC x HF: Health care expenditure by function and by financing scheme: data on how are the different types of services and goods financed;
• HP x HF: Health care expenditure by provider and by financing scheme: data on from which health care provider and under which particular financing scheme are the services and goods purchased.

The classifications and definitions presented in the SHA 2011 manual are to be followed. Additional guidelines and material useful for compilers are also available at this address.

Commission Regulation (EU) 2021/1901, and Commission Regulation (EU) 2015/359 previously in force,  concern the collection of data on "current expenditure on healthcare" which is defined as the "final consumption expenditure of resident units on health care goods and services".

There is a very close relationship between the concept of "final consumption expenditure" as defined in the System of Health Accounts (SHA) and in National Account and, as a consequence, also between the underlying economic transactions as recorded in the two accounting frameworks.

In National Accounts there are two types of statistical units: institutional units and local kind-of-activity units (KAU). A local KAU groups all the parts of an institutional unit in its capacity as producer which are located in a single site. A local KAU belongs to one and only one institutional unit.

SHA uses the same two types of units for data compilation.

Local KAUs operating as providers of healthcare goods and services to resident units are statistical units in SHA.

Also transactions by institutional units are recorded in SHA, in which framework institutional units are also referred to as "financing agents". More precisely, SHA financing agents are institutional units that manage one or more financing schemes. The transactions are executed by the financing agents, according to the rules of the financing schemes.

Financing agents serve as key statistical units in producing national health accounts. While financing schemes are the key units for analysing how the consumption of health care goods and services is financed, the data concerning the relevant transactions are collected either from the financing agents that operate the different financing schemes or from the providers.

The concept of "healthcare financing schemes" in SHA is an application and extension of the concept of "social protection schemes" defined by the European System of Social PROtection Statistics (ESSPROS):  "a distinct body of rules, supported by one or more institutional units, governing the provision of social protection benefits and their financing ...". The social protection scheme is the statistical unit in ESSPROS. It is an analytical unit that allows describing the complete structure of the social protection financing system:  expenditure and receipts.

According to SHA Manual 2011, "the key concepts for describing the structure of the health care financing system are based on measuring: (a) the expenditure of health care financing schemes, under which goods and services are purchased directly from health care providers, on the one hand, and (b) the types of revenues of health care financing schemes, on the other hand.  

Commission Regulation (EU) 2021/1901  and (prior Commission Regulation (EU) 2015/359) limits its scope to the collection of data on the expenditure of health care financing schemes.

SHA focuses on the consumption of health care goods and services by the resident population irrespective of where this takes place. This implies the inclusion of imports (from non-resident providers) and the exclusion of exports (health care goods and services provided to non-residents).

The data aims at providing a complete overview of expenditure on health care goods and services consumption of services and goods by the resident population on the national territory of a country.

Data are available from 1992 onwards.

Not applicable.

Current expenditure data are presented according to following units:

• expenditure amount in millions of euro;
• expenditure amount in millions of national currency;
• expenditure amount in millions of PPS;
• percentage of GDP;
• amount in euro per capita;
• amount in national currency per capita;
• amount in PPS per capita;
• percentage of current health expenditure (CHE).

Health care expenditure data are annual data, corresponding to the calendar year. This quality report covers the following reference years:1992-2022.

Countries submit data to Eurostat on the basis of Commission Regulations (EU): 

• 2015/359 of 4 March 2015 implementing Regulation (EC) No 1338/2008 of the European Parliament and of the Council as regards statistics on healthcare expenditure and financing, until the reference year 2020.
• 2021/1901 of 29 October 2021 implementing Regulation (EC) No 1338/2008 of the European Parliament and of the Council as regards statistics on health care expenditure and financing, for which the first reference year will be in 2021.

The implementing Regulations specify the areas and the level of aggregation to be submitted by EU Member States and EEA countries (see Annex II of the Regulation).

Data collection takes place in agreement with the World Health Organization (WHO) and the Organization of Economic Co-operation and Development (OECD).

The Regulation (EC) No 223/2009 on European statistics (recitals 23-27, 31-32 and Articles 20-26) applies.

Since only aggregated data or statistics without direct personal reference are used and since this is a macroeconomic consideration, no additional confidentiality procedures are necessary/applied.

Not applicable.

Please refer to the Release calendar - Eurostat (europa.eu) and publicly available on the Eurostat’s website.

In line with the Community legal framework and the European Statistics Code of Practice Eurostat disseminates European statistics on Eurostat's website (see item 10 - 'Accessibility and clarity') respecting professional independence and in an objective, professional and transparent manner in which all users are treated equitably. The detailed arrangements are governed by the Eurostat protocol on impartial access to Eurostat data for users.

Annual.

• Destatis (home).
• GBE (Bund).

Not applicable.

Delivery of data via the Joint Health Accounts Questionnaire (JHAQ) to the international organizations Eurostat, OECD and WHO.

The quality report for the National System of Health Accounts is only available in German language at the Destatis website.

Authorities responsible for SHA data collection work to ensure that the statistical practices used to compile national health accounts are in compliance with SHA methodological requirements and that good practices in the field are being followed, according to the methodology underlined in the SHA 2011 Manual and European Statistics Code of Practice respecting professional independence of the statistical authorities. Procedures are in place to plan and monitor the quality of the health care expenditure statistical production process.

In general, we rate the data quality as good.

The data are used by different user groups. Politics, administration, media, associations, chambers, education, science, private users etc.

Not available.

In principle, all content-related requirements of the relevant laws, regulation and guidelines are fulfilled. If there are deviations, these are described in the sources and methods.

The sources to compile the data on health care expenditure are mainly administrative and register-based data, only a small percentage of the figures come from surveys or other means. Accordingly, for the health care expenditure data collection, accuracy deals with problems of coverage as the main possible source of errors.

Not applicable.

The sampling and non-sampling errors in the basic statistics used can in principle also be included in the results of the Health Expenditure Accounts.  In addition, there are possible distortions caused by estimation procedures and updating of time series.  However, it should be noted that most basic statistics are full surveys of high quality and estimates are only made in peripheral areas where reliable data is missing.  Due to this situation, it is not possible to quantify the overall error with certainty.  Overall, we assume good data quality when calculating health expenditure by sources of funding.  Limitations arise due to the insufficient data available when calculating health expenditure by private households and private non-profit organizations.  There may also be further restrictions in the three-dimensional distribution of health expenditure according to sources of funding, functions of healthcare and healthcare providers in certain areas such as prevention for example.  Breaks in time series are also possible due to methodological changes in the corresponding databases.  This applies e.g. for the presentation of medical or therapeutic services in statutory health insurance for the reporting year 2010.

Member States were required to transmit their data to Eurostat in compliance with the Commission Regulation (EU) 2015/359 transmission deadlines, until reference year 2020. As of reference year 2021, data are transmitted pursuant to Commission Regulation (EU) 2021/1901.
Data and reference metadata for the reference year T should be transmitted to Eurostat by 30 April T+2.

The data are delivered to the international organizations on schedule.

Not applicable.

Data from 1992 onwards corresponds to Germany after reunification, reported in the format of the System of Health Accounts (SHA).
There is a break in the series in social health insurance in 2010. Different databases are used for the distribution of expenditure before 2009 and as from 2010.
The health expenditure on healthcare functions of the private insurance (or similar) is comparable to a limited extend only (before and after 2015) due to the fact that the distribution key is based on an enlarged sample after 2015.
Over- or underestimation is possible on the items where the residual method is used. NPISH expenditures are derived from National Accounts data and are calculated on a pro rata basis (expecially an overestimation in long term care is possible). Furthermore data on public health service can be incomplete.

The data are not reconciled with other domains such as ESSPROS.

Atypical entries are variables of two dimensions that should not intersect. Either these
items are so specific in health accounts that the vast majority of countries do not record
any transactions under these variables or it is unusual to find them in a country health
accounts. In DE the following atypical entries are identified in the joint questionnaire :

• Costs for offices which assess if patients are eligible for services of curative care. Those offices belong to the social health insurance agencies and are therefore attributed to HP.7.2.
• Costs for offices which assess if patients are eligible for services of long-term care. Those offices belong to the social insurance agencies and are therefore attributed to HP.7.2.
• Costs for offices which assess if patients are eligible for services of long-term care. Those offices belong to the private health insurance administration agencies and are therefore attributed to HP.7.3.
• Costs for offices which inspect companies if they comply with saftety at work regulations. Those offices belong to the statutory accident insurance.
• Expenditure for the administration of the reimbursement of services provided abroad.

To calculate health expenditure, data from around 35 data sources are brought together.  These are predominantly business and financial results, statistical and financial reports, budget plans and industry reports.  Where available, the basic values ​​come from full surveys; in individual cases, sample results, for example from the microcensus or studies, are also used.  In addition to the annual financial and business results of the Federal Ministry of Health, the important basic statistics include for example:

• Statutory Health Insurance Funds: Financial Records (KJ1-Statistics);
• Federal Budget;
• Statutory Accident Insurance Funds: Financial Records;
• Statutory Long-term care Insurance Funds: Financial Records (PJ1-Statistics);
• Statutory Pension Insurance Scheme: Financial Records of Pension Schemes for Workers, Employees, Miners and agricultural Workers;
• Statistics of Public Finances (Haushalt des Bundes, der Länder und der Kommunen);
• Social Welfare Statistics;
• Statistics on the benefits for the victims of war;
• Financial records of the Federal Employment Agency;
• Statistics on benefits for asylum-seekers;
• Financial records of the Health Insurance for civil servants employed at Deutsche Post and Deutsche Bahn;
• Long-term care statistics;
• Federal Association of Optricians (statistics);
• Private Health and Private Long-term Care Insurance (Financial Records);
• Ministry of Family Affairs, Senior Citizen, Women and Youth and Ministry of Health;
• Statistics of cost structure in offices of physicians by federal statistical office;
• Statistics on co-payments of statutory health insurance;
• National Accounts;
• Records of the Association of German Social Welfare Organisations (BAGFW);
• Statistics of cost structure in dental practices;
• Sales tax statistics of federal statistical office;
• Data of German Medicines Manufacturers' Association.

Annual.

Data are collected through the joint health accounts questionnaire (JHAQ) that is submitted to Eurostat during the annual data collection exercise. There is a voluntary deadline to send the JHAQ questionnaire for the calendar year T by the 31st of March T+2. The joint health accounts questionnaire (JHAQ) is coordinated in agreement with the World Health Organisation (WHO) and the Organization of Economic Co-operation and Development (OECD). These three international organisations are known collectively as the International Health Accounts Team (IHAT). Data are submitted to Eurostat based on Commission Regulation (EU) 2015/359 of 4 March 2015 implementing Regulation (EC) No 1338/2008 of the European Parliament and of the Council as regards statistics on healthcare expenditure and financing, until reference year 2020. As of reference year 2021 onwards Commission Regulation (EU) 2021/1901 of 29 October 2021 implementing Regulation (EC) No 1338/2008, is in force.

The JHAQ includes a number of features which allow national data correspondents to perform various quality checks before submitting the data. The embedded programmes allow the verification of:

1- Consistency of the data between tables,
This step checks if the marginal totals reported in each table of the JHAQ are consistent across all tables. For example, for each function (HC), the total across all financing schemes (HF) in the HCxHF table has to be equal to the total across all providers (HP) in the HCxHP table, i.e. the values in the column “All HF” in the HCxHF table have to be equal to the values in the column “All HP” in the HCxHP table. Any detected differences are flagged up in the corresponding row or column in the relevant tables and all inconsistencies are listed in the “Report” worksheet by variable code together with the amount by which the respective variable differs between the two compared tables. A positive value indicates that the first listed table has a higher value for the same variable, and vice versa.

2- Consistency of the data within tables,
Any detected inconsistencies are listed by variable code together with an indication of which total is not equal to the sum of its subcomponents as well as the numerical difference. A positive figure indicates that the total is greater than the reported sub-components, and vice versa.

• The presence of negative values,

Entries in the tables cannot be negative as they refer to the consumption of goods and services.
If an individual data table is checked for internal consistency, the negative values check is performed for the relevant table and then any negative values are highlighted red and crossed out.

• The presence of atypical entries,

The atypical entries check provides information whether the data tables contain values in cells which are – if at all – only reported by very few countries and are thus atypical for health accounting.
If an individual data table is checked for internal consistency, the atypical entries check is performed for the relevant table. In the data tables, any cell containing an atypical entry will be highlighted for national data providers.
Should any atypical entries be identified, compilers should scrutinize in detail the transactions that led to entries in those cells and assess whether the accounting rules of SHA have been correctly applied. If they come to the conclusion that the transactions are recorded in the correct categories of the ICHA classifications, then the corresponding atypical entries represent unique – and correctly accounted for – features of the country’s health system. In this case a short description of the nature of the transactions should be included in the accompanying Metadata file under “II.3. Atypical entries”.
If, on the other hand, compilers come to the conclusion that the transactions are not recorded correctly, then they need to make adjustments in the concerned tables. In case the transactions recorded in a cell do not belong to the boundaries of SHA (e.g. they refer to intermediate consumption) the value of the respective cell should be deleted (and all cells that are affected by this change adjusted accordingly). In case the transactions are misreported and another category of the ICHA classification is more appropriate, the value of the cell should be transferred to the correct cell of the table.

3- The growth rates against the previous year and the magnitude of revisions as compared to previously submitted data. Results are grouped into three different categories:

• Breaks in series (the current questionnaire shows no data for an item that is not null in the other file)
• Newly reported (the current questionnaire contains data for an item that is empty in the other file)
• Differences (all other types of differences)

The Health Expenditure Accounts is a secondary statistical calculation that combines the data sources available in the sector of ​​healthcare at the time of calculation - such as administrative data, sample surveys, business and annual reports as well as special evaluations - to determine the total expenditure on goods and services in the healthcare system.  The recording of health expenditure is primarily carried out by the sources of funding.  The expenses of the different sources of funding (e.g. statutory health insurance) must be assigned to the functions of healthcare and the healthcare providers that render these services.  For this purpose, appropriate quotas are sometimes calculated to distribute expenditure across the functions of healthcare and the healthcare providers rendering the functions.  Private household expenses are calculated differently.  As a rule, a residual value method is used.  The starting point is the turnover of healthcare providers.  Non-health-related sales, exports and all expenses from other sources of funding are deducted from this.  The residual represents the health expenditure of private households.

Some expenditure items require data extrapolation/intrapolation because current data is not available or data is missing for certain years.  For some other expenditure items, estimation methods must be used.
(see following table).

Not applicable.

No comment.