National Institute for Health Development

Health statistics department

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).

Estonia.

2003-2022.

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: 2014-2022.

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).

Activities of the National Institute for Health Development are regulated by the statutes of the Institute Tervise Arengu Instituudi põhimäärus–Riigi Teataja. This and other regulating acts are available at Instituudist | Tervise Arengu Instituut (tai.ee).

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.

The processing and use of data is carried out in accordance with the rules for handling confidential data, which are stipulated in the relevant legislation of the Republic of Estonia and the European Union.

For Healh Accounts compilation are used aggregated data, by HF, HC and HP. Published are only aggregated tables. For health services and goods compensated by EHIF pseudonymised microdata files are used for provision of aggregation. Those microdata is processed according to general data confidentiality and protection rules applied by the National Institute for Health Developmen (NIHD). NIHD as a personal data processor, collects personal data only to the extent necessary for the performance of the tasks stipulated in the statutes or by legislation.

Published annually at National Institute for Health Development public statistical database Health statistics and health research database (tai.ee) - Statistika tablelist - according to the Release Calendar of the database Statistika Resources.

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.

Press release is published annually together with the publication of new data in the public database.

Analyses are published at NIHD website under the publications ("Väljaanded").

Publications are available also in the public database under the Health expenditure tables "Detailed information" section.

Public Health statistics and health research database (Tervisestatistika ja terviseuuringute andmebaas), available at National Institute for Health Development website, under the section 'Healthcare resources and their use' in Estonian and in English.

Not applicable.

Data visualisation using Tableau is included, available at public database front page and in public database under the Health expenditure data tables detailed information section. 

Short description is available at public health statistics database under the Health expenditure data tables included in detailed information section.

All published health expenditure analysis include methodology chapter.

Data collection and compilation process is documented in the internal guidelines, which is updated annually. No recent quality reports are published.

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.

National Institute for Health Development operates as a central institution in charge of health statistics in Estonia. The Department of Health Statistics does data collection, analyses and publishing of health expenditure statistics in accordance with SHA methodology. The statistical information is produced by following the principles of objectivity, reliability, relevance, confidentiality and transparency. 

Overall quality is good. Bases on administrative data, which is complemented by special requests for function and provider details - collected by SHA-standardised form. Primary data are cross-checked with publicly available general economic data. 

Statistical quality principles are followed. Possibilities of using new available data sources are constantly being studied. Only solid data sources are used. To ensure comparability of time series, time series have been harmonized since 2003.

The work of supplementing and developing relevant data sources is ongoing. When a new better data source is found or new relevant information is revealed, recalculations are made to the time series to maintain the comparability of the time series. In 2023 was finished HC3 social welfare LTC services expenditure harmonisation in health accounts since 2003. 

Planned with EHIF to make a pilot attempt to separate HF31 and HF32 by health services (HC) and health providers (HP) based on EHIF Database. 

As Statistics Estonia does not plan any more to collect and provide to NIHD any data about private sector health expenditure (special module was used for 2008, 2013, 2018) and does not offer any alternatives, there is a need to find a new data source. Could be possible that Tax Authority data colletion include data about occupational health costs due to the fact that the special benefit is exempted from the tax, if these expenses are made in order to fulfill the occupational health and safety law, and in addition to the compensation of the health and sports costs of the employees up to 100 euros per employee per quarter, if it is allowed for all employees.

The main users of health care expenditure data are policy makers, research institutes, media, and students.

Main users of SHA data in Estonia are Ministry of Social Affairs, professional health associations, health professionals, media, researchers, students. Key indicators that are monitored and requested are health expenditure in general, public, private and household expenditure with services distribution, and the share of health expenditure in GDP.

In addition to user consultations, health statistics user satisfaction surveys are conducted by NIHD. Last one in 2024, previous in 2019 and published.

HF.3: From services over-the-counter medicines HC512 are without any cost sharing. Rest of the services include some cost sharing (HF321), but from household expenditure paid services without cost-sharing and services with cost-sharing are not distinguished. Categories HF.3.1 and HF.3.2 are included under HF.3. 

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.

The quality depends on the quality of administrative and reported data. No sampling surveys are used, except health spendings of private companies (EKOMAR module E, Statistics Estonia, latest in 2018). Out-of-pocket expenditure distribution between services is estimated.

Sample surveys are not used, only for health spendings of private companies.

Depending on the level of detail of the data used, coding in certain areas may be limited to a more general level.

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.

Timelliness is followed. National data are published in Estonian Health Statistics and Health Research Database annually by end-November T+1.

As planned, there were no deviations from deadlines in the reference period.

Not applicable.

Time series are harmonised since 2003.

Breaks in time series:

Calculations are cross-checked with other sources at national level.

Each data set of the different data source is compared to the previous year data, other data of data provider and with general data at national level.

There are 2 persons involved in production of health accounts, approximately 1,3-1,4 FTE together, depending on the year and needed development works. This estimate does not include the work of other agencies to prepare the necessary data (EHIF, Ministry of Social Affairs, National Health Board and other data providers).

To keep the response burden as minimal as possible mainly secondary use of readily available administrative and financial data is in place in data collection. Additional data on request are used in case of ministries, insurance companies and in some certain key data providers when detailed data is not publicly available for SHA compilation. Best estimates and approximations are accepted when exact details are not readily available.

Automatic control relationships are used when creating tables for publication and for Joint Questionnaire to save working time and to insure the quality of produced data.

Generally revisions have to be made only if new relevant information emerge or mistakes have been discovered. New health expenditure data are published T+11 months annually.

In 2023 was finished HC3 social welfare LTC services harmonisation in health expenditure for years 2003-2022, including both LTC health HC.3 and LTC social HCR1 data. New available information has been explored and included to health expenditure: since 2019 included employer's voluntary complementary medical insurance expenses (HF21). Household OOP expenditure for COVID-19 laboratory testing (PCR and other) is included for years 2020-2022. Clarifications in the COVID-19 costs resulted also the need for corrections in 2020-2022 health expenditure.

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 2023 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)

Applied estimation methods and adjustments to the original sources:

No adjustments have been made.

A brief description of the metadata is attached to the health expenditure tables published in the public health statistics database of the National Institute for Health Development (NIHD) website under tables "Detailed information".

In published health expenditure analysis, available at NIHD webpage under the Publications (Väljaanded) are included methodology chapter.