Central Statistical Bureau of Latvia

Social Statistics Department, Social Statistics Data Compilation and Analysis Section

1, Lāčplēša Street

Riga, LV-1301

Latvia

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 time coverage of this Quality report is 2014 to 2016 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,
- 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.

2013-2016.

Not applicable.

Several data sources are used:

-          Surveys/census: 4

-          Public administrative records: 1

-          Financial reports: 3

Surveys/censuses

Public administrative records

Financial reports

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.

Two institutions are involved in data compilation – National Health Service (NHS) and the Central Statistical Bureau (CSB). The responsibility of NHS is to maintain a unified system of settlements on health care services paid by the government budgetary funds, where each service provider that is in contractual relations with NHS, enters information on government budget funded services provided to each patient. NHS concludes agreements with medical institutions on the provision and payment of health care services. Exchange of information is done only electronically by using unified classifications and institutions enter information on health care services according to the accounting documents. In order to meet requirements of the Commission Regulation NHS in 2015 has worked out methodological guidelines how to process the entered data and other information and classify them according to the Classification of Medical Services (ICHA- HC).

The CSB collects information on private health expenditure, as well as on all other health care expenditures for which information is not provided by the NHS. As a result, the information is combined in data tables. For estimation of expenditure for the national SHA the Central Statistical Bureau follows several main conditions:
- to use provider side approach with a list of providers (including NACE 4774&4778); main activity and “pure” branch of the provider;
- to define that the expenditure related to health care providers is the totality of receipts of the providers in the execution of their activities;

- to use residual value for estimation private out-of-pocket expenditure with a joint estimation scheme and variables: net turnover of enterprises (for budgetary institutions  expenditure and income of budget institutions from paid services) minus direct budgetary allocations;
In order to calculate private expenditure several steps are applied:
The first step is to compare and equate the budgetary allocations for each provider according to the condition CSB_HF11 ≥ NHS_HF11 but not less than NHS_HF11 because an enterprise can get money for health services reimbursed from state from other financial agents like other ministries or local governments. In case when the CSB_HF11 is less (differs significant from NHS_HF11 data) we check (or correct if needed) the data on establishment level. 
The second step is to calculate private expenditure by subtracting from the total company turnover the public expenditure. Unfortunately, this does not make it possible to breakdown private expenditure in more detail – in to HF.3.1 and HF.3.2.

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)

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

Publication of data at national level is carried out using the same international standards, only data is not published as detailed as data aggregation tables.

Quality assurance requirements in Latvia are explained in the Guidelines for Implementation of European Statistics Code of Practice. Quality Guidelines is an informative document describing the CSB and the main aspects of its activity: stages, methods and organizational principles of producing the national statistics, policy of data protection and dissemination. The purpose of these Guidelines is to promote the implementation of the CSB’s operational strategy by involving in this process every employee of the CSB, developing the communication with society and extending the knowledge of every interested person – respondent, data user and all society – about the activity of CSB.

https://www.csb.gov.lv/sites/default/files/Dokumenti/revision_policy_csb.eng_.pdf

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.

The data for SHA tables are obtained from several data sources. At each data collection stage, the quality of the data is evaluated individually for each data source. Every year information is compared with previous years, risks, discrepancies or changes and their impact is being evaluated. Data quality gaps are fixed before data is placed in SHA tablesData quality gaps are fixed before data is placed in SHA tables.

As the managing institution of the PSOS, CSB has researched conformity to the Code requirements in Latvian statistical institutions producing European statistics including the National Health Survey. The NHS is main partner  for data collection for SHA.

Latvian State Agency of Medicine data covers 97% from all registered pharmacies.

Data users at the national level:

Ministry of Health (private expenditure);

Ministry of Finance (Long-term care – HC.3 and HCR.1; private expenditure);

Diseases Prevention and Control Centre (for national indicator database);

Data users – researchers working on public health and social care; dental care indicators;

Data users: National Accounts Section (for data comparisons).

Data users also use Eurostat database online and request to explain differences between total public expenditure by Government Finance Section of the CSB (according to the ESA 2010) and data collection according to the SHA approach.

Unmet user needs mainly relate to the timeliness of publication of data - data users would appreciate to get information faster.

The CSB of Latvia does not carry the data user’s satisfaction surveys.

Once a year, the CSB collects information on the number of views and number of downloads of the CSB database tables. In the near future, it is planned to include in the data base also the main financial indicators according to the SHA methodology.

See 5.3.1.

HCxHF

Missing (data not available)

HF.2.3 - there are cases when enterprises directly finance health services (for instance, occupational health care, reimbursement of glasses) but it is not possible to separate these expenditures.  Enterprises accounting reports also do not allow to distinguish these costs as they are included in the total labour costs.

HF.4 – data are not available

Missing (category reported elsewhere):

Disaster and emergency response programmes (HC.6.6) are included into HC.4.3.

HC.3.1 - 

Deviation from SHA definition:

HC.3 - A splitting between ADL,  IADL and "outside of LTC-health". We have no data on level of activity limitations of persons. People living in LTC  facilities are diverse. We must use another key for splitting

 HPxHF

Deviation from SHA definition:

Residential long-term care facilities (HP.2) - 

Missing (data not available):

There are some electronic shopping and mail-order enterprises in Latvia. However, there is no key to calculating what part to take for medical goods.

Households as providers of home health care (HP.8.1)

When calculating this indicator, we encounter several obstacles. It is difficult to determine the status of each cell (not applicable, missing, elsewhere reporting or insignificant value) due to lack of practice to apply information or do not know where to look for information. It mainly concerns financial schemes (HF2.3 or HF.4). There are cases also when cells are not recommended to fill at all (atypical). Would not it be possible to pre-show in the tables where these cells are, so that they cannot be included in the calculations and this would increase coverage.

HCxHF

63% (without “not applicable”)

HPxHF

69% (without “not applicable”)

HCxHP

70% (without “not applicable”)

After quality measures and verification the overall accuracy of Latvian data for SHA is good.

Not applicable.

Not applicable.

See 6.3.1.

Health care goods and services consumed by non-residents are included. In 2020 this problem will be solved. In 2019 the Diseases Prevention and Control Centre carried out survey asking health care providers to fill in questionnaire about services provided for non-residents. Some financial data also will be available.

Latvia is not able to report informal health care goods and services in the data collection.

Private expenditure will be improved, deducting from HF.3, the eligible expenses reimbursed by the state, that is, types of expenditures - planned operations and dentistry expenses, or other expenditure on health - are deducted from taxable incomes when the annual tax declaration is submitted. Accordingly, to the Law On Personal Income Tax, in a year a person receives 23 % of expenses for medical services. 

During the data compilation, estimates are made for the units that are included in the list of health service providers, but health is the 2nd or 3rd enterprise activity. In these cases, the proportion of health services is calculated as the contribution of medical staff. 

Not available.

Not available.

Not available.

The CSB obtains data on SHA using provider side approach and list of providers for HP.1, HP.3, HP.4, HP.6 and HP.7, drawn up by the Health Inspectorate that determines the right to provide healthcare services.

For HP.2 the register of Ministry of Welfare is used. In this case, the problem is not in the unit level, but rather how to calculate functions (services) ADL and IADL if the data source is not available.

For HP.5.2 there is a special list for collecting information on hearing aids and medical products (NACE4774 and NACE 4778).

Not available.

Not available.

Not available.

Not relevant.

Not applicable.

Not applicable.

The revision of SHA tables occurs when the methodology is being changed.

The revision of SHA tables occurs when the methodology is being changed.

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.

Not available.

Not available.

Latvia complies with the Commission Regulation 359/2015 transmission deadlines, which is  30 April t+2 for reference year t.

Not available.

Not applicable at national level.

Not applicable.

Data according to the SHA 2011 methodology is comparable over the time with no break in time for 2014 to 2016 data.

4 years (2013 to 2016) for SHA 2011 data.

Comparison of SHA and ESSPROS data collection approaches was carried out in 2015 in the frame work of Grant project "Health Accounts (SHA 2011)".

During the reference period, it was possible to calculate national SHA (SHA2011) for 2013 (new methodology). Unfortunately, for mapping SHA codes to ESSPROS codes we used template “Harmonization table” from the document “ESSPROS and SHA an investigation on the possibility of Harmonization” (2006) afterwards adapted this table with some re-codification of the SHA 1.0 version codes to SHA2011. If necessary, it is possible to make comparisons between data collection systems of ESSPROS and national SHA. The differences for the total figures reach 1.8% however if the results are analysed between the subgroups the differences are increased but could be interpreted.

Not applicable.

Comparison of SHA and SNA data collection approaches was carried out in 2015 in the frame work of Grant project "Health Accounts (SHA 2011)". Results from SNA and SHA differ due to the scope of health care goods and services included and the estimation methods used. From provider side of health services SNA uses NACE classification of economic activities 4-digit levels recorded under category 86 – Human Health including 8610, 8621, 8622, 8623 and 8690.  In contrast, SHA boundary is broader, including partly NACE 87, administration, optical and vision products, medical appliances and non-durables (NACE 4774), partly - laboratory services providers which code their economic activity not as NACE 8690 but, for instance, NACE 7120, NACE 3250 or NACE 8423. 

No press releases at national level have been published.

Latvian Health and Health Indicator Database (in Latvian)

https://www.spkc.gov.lv/lv/statistika-un-petijumi/datu-bazes

Health in the Baltic Countries

https://www.spkc.gov.lv/lv/statistika-un-petijumi/statistika/health-in-the-baltic-countries

SHA data are not disseminated in the CSB on-line database.

SHA data are not disseminated in the CSB on-line database.

Not applicable.

Latvian Health and Health Indicator Database (in Latvian)

https://www.spkc.gov.lv/lv/statistika-un-petijumi/datu-bazes

CSB Statistical Year book 2018

Not available.

Not available.

Not available.

Not available.

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

As data tables use aggregates from several data sources, the confidentiality of every data sources could be applied. 

No further comments.