Istituto Nazionale di Statistica (Istat)

Department for Statistical Production

Directorate for National Accounts (DCCN)

Division “Supply of goods and services and institutional sectors accounts”

 Italian National Institute of Statistics (Istat)

Via Agostino Depretis 74B - 00184 Roma, Italy

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).

The Italian National Institute of Statistics transmits data for the reference year T and, on voluntary basis, T+1 with the same level of details, by April T+2.

The time coverage of this Quality report is 2012 to 2017 reference years.

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:
i. Occupational health care (intermediate consumption within establishments) minus an estimated share of occupational health in health providers’ and other medical industries net administration;
ii.“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.

Commission Regulation 2015/359 concerns 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 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.

2012 onwards (until year T, under SHA 2011 methodology, disseminated by Eurostat).

Not applicable.

Several data sources are used:

-          Surveys/census: 3

-          Public administrative records: 9

-          Financial reports: 2

-          Other: 4

Surveys/censuses

Public administrative records

Financial reports

Other

Annual.

Data are collected through the joint health accounts questionnaire (JHAQ) that countries submit 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). Countries submit data to Eurostat on the basis of 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.

The sources used by Italian National Institute of Statistics (Istat) for the production of SHA 2011 data include both surveys, and administrative data. A large part of these data is already collected annually, through a web-based tool, for the purpose of National Accounts and GFS/EDP compilation.

The main sources of the administrative data used to estimate public health care expenditure are provided by the Ministry of Health using a web-based tool and by e-mail.

Information on health and social care interventions for the provision of assistance to adult persons with psychiatric problems and to their families are available in the report published on the website of the Ministry of Health.

Information on the use of drugs and patients under treatments are available in the Annual Report to the Parliament on the Status of Drug Addiction in Italy based on National Information Dependency System (SIND) published on-line.

The main data source for the Household out-of-pocket expenditure is the Household Budget Survey (HBS), supplied by other divisions of Istat.

Report for medical products are published on the website of Italian Medicines Agency (AIFA).

Data for voluntary insurance are transmitted by the Institute for the Supervision of Insurance (IVASS) by e-mail.

Residual data are collected on Internet.

The 2018 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 Italian National Institute of Statistics carries out several in depth controls of the SHA data, before the transmission of JHAQ. Data are compared with information from other independent sources. The consistency between the data, of the year and of previous editions is checked and evaluated. The available time series are analyzed and double-checked, looking for trends and anomalies; finally the adequacy of the estimates is assessed and compared to the definitions provided by SHA2011 manual.

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-/interpolate 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.

No adjustment are performed.

Authorities responsible for SHA data collection are working 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.

Since the 90s Istat adopted a systematic approach to ensure quality in both statistical information and service to the community. For this purpose, the Italian National Institute of Statistics has defined a quality policy providing itself with appropriate tools as well as management changes to carry it out.
Istat quality policy is aimed at the improvement of statistical outputs and processes through the development of appropriate methodologies and tools as well as an appropriate scientific and technical support, provided to the personnel directly involved in the production and dissemination of statistical information.

Istat quality policy is coherent with the European framework developed by Eurostat, taking up its main principles and definitions. The European Statistics Code of Practice establishes the principles to follow in order to ensure and strengthen both accountability and governance of the European Statistical System and the National Statistical Systems inside it. Essential point of Istat quality policy are:

- Process quality: consisting in the production of accurate statistical information efficiently and effectively;
- Product quality: consisting in the dissemination of high-quality timely statistical data which are relevant for the users, also the potential ones;
- Documentation: consisting in the storage and availability of information necessary not only for a proper use of data but also to ensure transparency in all the production activities of statistical data;
- Respect for respondents: consisting in the reduction of response burden and in the respect of respondent’s privacy;
- Strengthening of statistical literacy: consisting in promoting a proper use of statistical information in policy-making to better support decisions and policies;
- Users’ orientation: consisting in making statistical information easily accessible and understandable and in satisfying user needs as much as possible. 

For details: https://www.istat.it/en/organisation-and-activity/institutional-activities/quality-commitment

The overall quality assessment for SHA is positive.

 The long experience of Italy in carrying out expenditure estimations for National Accounts according to European rules established in Regulations has been fundamental to reduce quality problems.

 The main strengths of SHA are:

• The use of administrative data of good quality providing very detailed information.
• The adoption of estimation methodologies developed in a national Working Group with the participation of several different institutions, among them the Ministry of Health, the Ministry of Economy and Finance, the Italian Medicines Agency.

 Out of Pocket data are compiled starting from National Account data already subjected to quality check.

SHA data provide key information for economic policy monitoring and decision making, for forecasting, for administrative purposes, for informing the general public (directly or indirectly via news agencies), and as input for economic research.

The main users are public administrations as the Ministry of Economy and Finance (mainly interested on long term care and private health expenditure) and the Ministry of Health.

Main non-public users are research institutions, and independent researchers working on public and private health care expenditure.

Users usually ask information on the difference between the health expenditure under SHA methodology and the data on health expenditure reported in other National accounts statistics.

Among the most requested indicators, it is possible to find health expenditure in general, public and private expenditure on long term care, and expenditure on hospitals.

The main users’ unsatisfied need is the Regional break down of health expenditure under SHA methodology.

Istat is constantly interested in understanding who are the users of the statistics produced, what are their information needs and whether these correspond to the outputs, and if the statistics produced satisfy the users. To this end, alongside the analysis of user requests received via the Web Contact Center service, direct consultation tools have been developed such as the annual online survey of Customer satisfaction and indirect tools such as the analysis of accesses and paths of site navigation and information search methods. To complete the Istat user involvement strategy, the Statistical Information Users Commission (Cuis) was established in 2011, with the aim of assisting the Institute in recognizing the statistical information demand expressed by the public and private institutions  and by society as a whole. The Commission currently consists of about 50 members, represented by associations, bodies and institutions that use official statistical information. It deals with evaluating the compliance of official data with users' needs and reporting any information gaps, proposing solutions to fill them.

Among the compulsory variables of the HF categories, the category HF4 “Rest of the world financing schemes (non-resident)” is missing because the data are not available.

HF.2.1 “Voluntary health insurance schemes” data are related to voluntary non-life insurance (sickness claims) and don’t report components on supplementary/complementary health insurance. This last category, existing in Italian health system, is not reported because detailed information, to give an exhaustive representation of it in National Accounts and in SHA data, are not available.

For the category HF.2.3 “Enterprise financing schemes”, the data are partially missing since the estimates reported are related only to occupational health outsourced (contracted out to offices of medical specialists), that in National Accounts are included in intermediated consumption. The occupational health care can be also provided in-house but, currently, sources to estimate it are not identified. Enterprises can also finance or provide directly health care services as a part of the overall benefits for employees; also in this case, at the moment, there is not an estimate of this kind of services due to the lack of detailed information in data sources.

The HC and HP compulsory categories are complete.

Table HCx HF = 90%

Table HPx HF = 90%

Table HCxHP = 100%

SHA data for Italy are the result of an integration process of data from different data sources, starting from National Accounts data.

 The coherence of SHA data with the National Accounts data according to the SEC2010 increase the accuracy of the estimations.

Not applicable.

Not applicable.

This section is not relevant.

Consistent with National Accounts, SHA data include informal payments. Health care goods and services by non residents are excluded according to resident concept required by SHA definitions.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

In principle, the revision follows the same policy of the General Government consolidated account in accordance with European rules concerning EDP statistics (Council Regulation No 3605/93). Then with the transmission, in the year T+2, of reference year T there could be revisions till the year T-2 data.

The data are revised once a year and are coherent with General Government data (EDP Notification April T+2) and National Accounts data released in March T+2.

The average size of revisions of the total current health expenditure is 0,19% (calculated using Relative Mean Absolute Revision - RMAR).

Member States are required to transmit their data to Eurostat in compliance with the Commission Regulation 359/2015 transmission deadlines.
Data and reference metadata for the reference year T should be transmitted to Eurostat by 30 April T+2.

The Italian National Institute of Statistics transmits data for the year T and T+1 with the same level of details by April T+2. At same time, Istat transmits also the updated data for the previous years, if necessary.

Istat publishes provisional figures for the year  T+1 in June of year T+2.

Final data for the year T are published in June of year T+2.

The transmissions were late of one day in year 2016 and two days in 2017. In year 2018 the deadline was respected.

See point 7.2.

Not applicable at national level.

Not applicable.

Data according to SHA 2011 methodology are available only from 2012 to 2017 (T+1), without any break.

6 years (2012-2017).

The boundaries, the methodologies, and the purposes of the health care expenditure of SHA and ESSPROS statistics are different; for example, SHA is based on the final consumption, while ESPROSS on the total current expenditure.

Istat transmits ESSPROS data on General Government health expenditure accordingly to the definition of the Part 1 chapter 2.2 point 16 and of chapter 2.3.4 point 23 of the ESSPROS Manual 2016, with the consequence that only the public expenditure is considered compliant with the definition provided.

Istat compiles the SHA data using different methodologies than ESSPROS.

The item General Government total current health expenditure, is reconciled across various domains (National Accounts-COFOG, ESSPROS, SHA). These reconciliation tables are for internal analysis and for institutional users.

Not applicable.

In general, the SHA data are coherent with National Accounts. The consistency between HF.1 “Government schemes and compulsory contributory health care financing schemes” reported in SHA data and final consumption expenditure by COFOG, class 7, is assured.

Out of Pocket expenditure are coherent with household expenditure on health estimated in National Accounts, classified by COICOP. However, conceptual differences exist between COICOP and SHA but sources allow transposing COICOP definitions into SHA framework. In National Accounts health expenditure financed by insurance is included in household final consumption expenditure, whereas according to SHA it is reclassified from HF.3 to HF.2.1. Moreover, National Accounts refers to the domestic concept whereas SHA refers to the resident concept. This implies that the total amount of expenditure in health goods and services on SHA does not match with National Accounts.

The internal coherence of SHA tables is checked with statistical procedures and assured before the transmission to EUROSTAT.

Only with the first dissemination at national level of SHA data Istat published a press release:

Statistiche Report - Il sistema dei conti della sanità per l’Italia - Anni 2012-2016.

https://www.istat.it/it/archivio/201944

A shorter version in English is available at the following link

https://www.istat.it/en/archivio/201949

Rapporto Osservasalute (2017, 2018). Stato di salute e qualità dell’assistenza nelle regioni italiane, Osservatorio nazionale sulla salute nelle regioni italiane. “La sanità italiana nel confronto europeo” https://www.osservatoriosullasalute.it/rapporto-osservasalute

The data are disseminated online both in Italian and English language on I.Stat the warehouse of statistics currently produced by the Italian National Institute of Statistics.

http://dati.istat.it/Index.aspx?QueryId=29021&lang=en

In the period June-December 2018, there were 2,333 consultations of the subdomain System of Health Accounts in I.Stat.

Not applicable.

The total current health care expenditure and long term care expenditure for General Government under SHA methodology are published every year in “Le tendenze di medio-lungo periodo del sistema pensionistico e socio-sanitario” by the Ministry of Economy and Finance.

http://www.rgs.mef.gov.it/VERSIONE-I/attivita_istituzionali/monitoraggio/spesa_pensionistica/index.html

The link for the 2016 English version is the following:

http://www.rgs.mef.gov.it/_Documenti/ENGLISH-VE/Institutio/Social-exp/Forcast-ac/Mid-long_term_trends_for_the_pension_and_health_care_systems_2016.pdf

The methodology used to estimate SHA data is reported in Italian language in the section “Nota Metodologica” of press release Statistics-Report - The System of Health accounts in Italy. Years 2012-2016. Edition: 2017, Reference period for data: Years 2012-2016;

https://www.istat.it/it/archivio/201944

Methodology used is also described (both in Italian and in English language) in I.Stat, alongside the data, at the following link:

http://dati.istat.it/OECDStat_Metadata/ShowMetadata.ashx?Dataset=DCCN_SHA&Lang=en

The Istat Information System on Quality (SIQual) (http://siqual.istat.it/SIQual/lang.do?language=UK) contains metainformation on the statistical production processes carried out by Istat. It includes metadata on process content, its operational characteristics (process phases and operations) and the quality considered both in terms of activities of prevention, monitoring and evaluation of errors (quality actions).

For details on SHA:

http://siqual.istat.it/SIQual/visualizza.do?id=8889051&refresh=true&language=EN

Not applicable.

Data not available.

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

 In Italy, according to the article n. 9 of the Legislative Decree n. 322 of 6 September 1989 data collected by statistical offices within the statistical surveys included in the National Statistical Programme may not be disclosed other than in aggregated form such that no reference to identifiable people can be extracted. Furthermore, they may be used only for statistical purposes. Data may not be communicated or disseminated neither to any external subject, public or private, nor to any department of the public administration other than in aggregate form and using modalities which prevent the identification of the people involved. In any case, data cannot be used to identify again the people involved. The Code of Conduct annexed to the Legislative Decree no. 196 of 30 June 2003 (Personal Data Protection Code) provides special rules concerning the processing of personal data for statistical purposes within Sistan. In order to make statistical secrecy and protection of personal data effective, Istat is currently taking appropriate organisational, logistical, methodological and statistical measures in accordance with internationally established standards. In accordance with the Personal Data Protection Code, respondents are informed of their rights and obligations with regard to the provision of information, and they are assured that the information they provide will be used for statistical purposes only.

Only aggregated data or statistics are used in the SHA estimation process without personal information, and then no additional confidentiality procedures are applied.

There are no additional comments.