Hellenic Statistical Authority (ELSTAT)

Division of Social Statistics Department of Health Statistics and Social Security and Protection

46 Peiraeus and Eponiton street 185 10, Peiraeus

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.

Covers the geographical area of Greece.

ELSTAT publishes SHA2011 data on an annual basis, within the first quarter of the second year after the reference year of the data, according to the timetable of publications of the OECD and Eurostat.

In particular, ELSTAT publishes statistical data of the System of Health Accounts (SHA2011) for the years 2009-2022 with first reference year, the year 2009.

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: 2003-2022.

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.

The issues concerning the observance of statistical confidentiality by the Hellenic Statistical Authority (ELSTAT) are arranged by articles 7, 8 and 9 of the Law 3832/2010 as in force, by Articles 8, 10 and 11(2) of the Regulation on Statistical Obligations of the agencies of the Hellenic Statistical System and by Articles 10 and 15 of the Regulation on the Operation and Administration of ELSTAT.

More precisely:

      ELSTAT disseminates the statistics in compliance with the statistical principles of the European Statistics Code of Practice and in particular with the principle of statistical confidentiality.

Protection of personal data

ELSTAT abides by the commitments and obligations arising from the applicable EU and national legislation on the protection of the individual from the processing of personal data and the relevant decisions, guidelines and regulatory acts of the Hellenic Data Protection Authority.

Pursuant to the Regulation on the protection of natural persons with regard to the processing of personal data [Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 (General Data Protection Regulation - GDPR)], ELSTAT implements the appropriate technical and organisational measures for ensuring adequate level of security against risks for the personal data it collects and has access to, in the context of carrying out its tasks, in order to meet the requirements of this Regulation and to protect these personal data from any unauthorised access or illegal processing.

The personal data collected by ELSTAT are used exclusively for purposes related to the conduct of surveys and the production of relevant statistics. Only ELSTAT has access to the data. The controller is the person appointed by law pursuant to the relevant provisions concerning the Legal Entities of Public Law and the Independent Authorities. The data are stored in the databases of ELSTAT for as long as required by the relevant legislation.

Legal basis of the processing: Article 6, para 1(c) and 1(d) of the General Data Protection Regulation (GDPR).

• ELSTAT protects and does not disseminate data it has obtained or it has access to, which enable the direct or indirect identification of the statistical units that have provided them by the disclosure of individual information directly received for statistical purposes or indirectly supplied from administrative or other sources. ELSTAT takes all appropriate preventive measures so as to render impossible the identification of individual statistical units by technical or other means that might reasonably be used by a third party. Statistical data that could potentially enable the identification of the statistical unit are disseminated by ELSTAT if and only if:

a) these data have been treated, as it is specifically set out in the Regulation on Statistical Obligations of the agencies of the Hellenic Statistical System (ELSS), in such a way that their dissemination does not prejudice statistical confidentiality or

b) the statistical unit has given its consent, without any reservations, for the disclosure of data.

• The confidential data that are transmitted by ELSS agencies to ELSTAT are used exclusively for statistical purposes and the only persons who have the right to have access to these data are the personnel engaged in this task and appointed by an act of the President of ELSTAT.
• ELSTAT may grant researchers conducting statistical analyses for scientific purposes access to data that enable the indirect identification of the statistical units concerned. The access is granted provided the following conditions are satisfied:
  
  a) an appropriate request together with a detailed research proposal in conformity with current scientific standards have been submitted;
  
  b) the research proposal indicates in sufficient detail the set of data to be accessed, the methods of analyzing them, and the time needed for the research;
  
  c) a contract specifying the conditions for access, the obligations of the researchers, the measures for respecting the confidentiality of statistical data and the sanctions in case of breach of these obligations has been signed by the individual researcher, by his/her institution, or by the organization commissioning the research, as the case may be, and by ELSTAT.
• Issues referring to the observance of statistical confidentiality are examined by the Statistical Confidentiality Committee (SCC) operating in ELSTAT. The responsibilities of this Committee are to make recommendations to the President of ELSTAT on:
  •  the level of detail at which statistical data can be disseminated, so as the identification, either directly or indirectly, of the surveyed statistical unit is not possible;
  • the anonymization criteria for the microdata provided to users;
  •  the granting to researchers access to confidential data for scientific purposes.
• The staff of ELSTAT, under any employment status, as well as the temporary survey workers who are employed for the collection of statistical data in statistical surveys conducted by ELSTAT, who acquire access by any means to confidential data, are bound by the principle of confidentiality and must use these data exclusively for the statistical purposes of ELSTAT. After the termination of their term of office, they are not allowed to use these data for any purpose.
• Violation of data confidentiality and/or statistical confidentiality by any civil servant or employee of ELSTAT constitutes the disciplinary offence of violation of duty and may be punished with the penalty of final dismissal.
• ELSTAT, by its decision, may impose a penalty amounting from ten thousand (10,000) up to two hundred thousand (200,000) euros to anyone who violates the confidentiality of data and/or statistical confidentiality. The penalty is always imposed after the hearing of the defense of the person liable for the breach, depending on the gravity and the repercussions of the violation. Any relapse constitutes an aggravating factor for the assessment of the administrative sanction.
• Pursuant to the Regulation on the protection of natural persons with regard to the processing of personal data [Regulation (EU) 2016/679 of the European Parliament and of the Council, of 27 April 2016 (General Data Protection Regulation - GDPR)], ELSTAT implements the appropriate technical and organisational measures for ensuring adequate level of security against risks for the personal data it collects and has access to, in the context of carrying out its tasks, in order to meet the requirements of this Regulation and to protect these personal data from any unauthorised access or illegal processing.

Data on the System of Health Accounts for the years 2009-2022 are available on ELSTAT’s website at:

• Statistics publication.
• Statistics portal.

Data on the System of Health Accounts for the years 2009-2022 are available on ELSTAT’s website.

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

News release available on ELSTAT’s website.

Data on the System of Health Accounts for the years 2009-2022 are available on ELSTAT’s website and on Eurostat’s website.

Data are available in ELSTAT’s data base.

Not applicable.

Not applicable.

The microdata are available upon request at:

Division of Statistical Information and Publications

46, Peiraeus & Eponiton str., 185 10 Peiraeus

Tel. (+30) 213-1352173, FAX : (+30) 213-1352022

e-mail : data.dissem@statistics.gr

Confidentiality of data is always ensured.

Categorization of health expenditures is based and is analytically described at: the System of Health Accounts as presented by the OECD in 2011.

The quality assurance system is presented on ELSTAT’s website at: Statistics ELSTATQuality Instructions EN.

As well as within the European Statistics Code of Practice, which was established by the Statistical Programme Committee in February 24, 2005 and published as Commission Recommendation in May 25, 2005, regarding the independence, integrity and responsibility of national and community statistical Authorities after its revision which was adopted in September 28, 2011 by the Commission of the European Statistical System.

The basic advantages of the overall quality of the System of Health Accounts compilation refer to the availability of primary data sources from the official national administrative sources (Ministry of Health, Social Security Funds, ELSTAT, Church of Greece etc.).

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.

The basic advantages of the overall quality of the System of Health Accounts compilation refer to the availability of primary data sources form the official national administrative sources (Ministry of Health, Social Security Funds, ELSTAT, Church of Greece etc.).

However, the need of a detailed classification of total health expenditures by provider and by health care activity defines the need of re-examining the total operational structure of the health sector in every data revision for each reference year.

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

User satisfaction survey.

Currently, incidents of non-satisfaction by users have not been recorded referring to the published System of Health Accounts results. The last available results of the User’s Satisfaction Survey, are presented on ELSTAT’s website at: User satisfaction survey.

The Division of Statistical Information and Publications of ELSTAT, conducts the survey on User’s satisfaction.

The completeness rate of data is considered satisfactory. However some three digit codes are no feasible to be completed and their respective sub-category is included within its broader (two digit) health category.

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 survey is a census survey; there are no sampling errors.

We use census not samples. 

Estimation for underground health goods and services are not included in the data.

Data on shadow economy are not included (for example data related to the shadow economy of home nursing care).

Accuracy of the data that are related to administrative sources is checked by themselves. Regarding the data that derive from ELSTAT’s Household Budget Survey (HBS), their accuracy is checked within the evaluation framework of the survey itself. Health care goods and services by non-residents are excluded from domestic providers. So far we were not able to report the informal /illegal health care goods and services within the data collection.

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.

No delays in the publication and transmission of data have been recorded.

Not applicable.

Coherence checks are carried out regarding the Social Security Funds survey of the Division of Social Statistics as well as with relevant data of the National Accounts Division and the ESSPROS data format. In particular scheme 18 of the ESSPROS data are based (on the uses side) on SHA2011 data (after the exclusion of non ESSPROS related data recorded in SHA2011).

The System of Health Accounts is compatible according to the three (3) tables compiled as they appear at ELSTAT’s website at: Statistics publication.

Data are checked against their internal consistency if two different data sources are used. However consistency among data does not seem to be a problem since both SHA2011 and national accounts data receive their primary data from the same data sources.

Non applicable.

Statistics documents.

Usually, data are revised every March following the reference year.

ELSTAT’s Revision Policy is being implemented as presented on ELSTAT’s website at: Statistics documents.

Several data sources are used (as of data notification in March 2022):

-          Surveys/census: 3

-          Public administrative records: 6

-          Financial reports: 0

-          Other: 0

Surveys/censuses

Public administrative records

The data are collected, stored and disseminated via different tables (expenditure by provider, by financing agency and by function). The data are collected from the following agencies:

•  the Ministry of Health , the Ministry of Defense,
•  the Ministry of Education,
•  all Social Security Funds,
•  the Household Budget Survey (HBS),
•  information collected from the Union of  Private Insurance Companies,
•  and various NPISHs.

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)

SHA data is compiled both by a bottom-up approach as well as by a top-down approach, depending on the data source. Compilation is done by financing schemes and by different health care functions/task areas. The results of the several calculations are then aggregated.

To gain the differentiation between the different SHA-dimensions (especially HC and HP) quotas and pro-rating and utilisation keys are applied on some spending items. For some spending items it is necessary to extra-/intrapolate data as there is no up-to-date data available or data is missing for certain years. For some other spending items, estimation methods have to be applied.

 Several methods are normally used for estimations:

• Balancing item/Residual method: For example, if data are available from the financing side, which permit accurate estimation of the flows to a provider or function, then an acceptable estimation method is to subtract these expenditure flows from the total revenues, and derive the expenditure flows from the unmeasured financing scheme as a residual.
• Pro-rating/Utilisation key: Typically in the absence of direct spending data, a utilisation key linked to the proportion of resources used can be constructed in order to distribute e.g. aggregate provider spending across functions. For every key a fraction of total utilisation within the cost-unit is assigned: fractions in the key must add up to 100% of all care delivered by the cost-unit. Examples of utilisation keys are admissions, bed-days, contacts, staffing, etc.
• Interpolation/Extrapolation: In the absence of data for the period in question, missing values can be estimated using known data points.
• Or other.

Data are compiled according to the Manual of the System of Health Accounts (SHA), 2011 edition. All expenditure items covering health and LTC are assigned a classification of provider and function. Data are included for military hospitals, and data for general population protection. Every effort is exercised to record data on an accrual basis and for this reason all data related to general government are compared with the respective health data of national accounts. Also COFOG data (health category GF07) are also taken into account, and compared with the SHA2011 data. Data are classified according to SHA2011 codification (categories HF,HP,HC) and are inserted on a unified working table covering all sectors, before being transferred to the formal JHAQ data.

No adjustment.

Statistics publications.