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F5: Education, health and social protection

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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). These categories form the 3 core classifications of the System of Health Accounts.

The complementary classification for the revenues of the health care financing schemes is also disseminated by Eurostat.

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;
• revenues of health care financing schemes (ICHA-FS) - which details the sources from which the financing arrangements get their revenues.

Public Health

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. The SHA shares the goals of the System of National Account (SNA) to constitute an integrated system of comprehensive, internally consistent, and internationally comparable accounts, which should as far as possible be compatible with other aggregated economic and social statistical systems.

The SHA is organised around a tri-axial system -which represents the consumption of health care goods and services- for the recording of health expenditure, by means of the International Classification for Health Accounts (ICHA), defining:

• health care by function (ICHA-HC)
• health care service provider industries(ICHA-HP) and
• health care financing scheme (ICHA-HF).

To extend the core accounting framework of SHA, complementary classifications can be linked to one of the three above-mentioned axes. Eurostat disseminates the additional classification related to the revenues of health care financing schemes (ICHA-FS). These data are provided by countries on a voluntary basis.

Health care functions

Healthcare functions relate to the type of need that current expenditure on healthcare aims to satisfy or the kind of objective pursued. The following main items are defined as:

• curative care, which means the healthcare services during which the principal intent is to relieve symptoms or to reduce the severity of an illness or injury, or to protect against its exacerbation or complication that could threaten life or normal function;
• rehabilitative care, which means the services to stabilise, improve or restore impaired body functions and structures, compensate for the absence or loss of body functions and structures, improve activities and participation and prevent impairments, medical complications and risks;
• inpatient care, which means the treatment and/or care provided in a healthcare facility to patients formally admitted and requiring an overnight stay;
• outpatient care, which means the medical and ancillary services delivered in a healthcare facility to a patient who is not formally admitted and does not stay overnight;
• day care, which means the planned medical and paramedical services delivered in a healthcare facility to patients who have been formally admitted for diagnosis, treatment or other types of healthcare and are discharged on the same day;
• long-term care (health), which means a range of medical and personal care services that are consumed with the primary goal of alleviating pain and suffering and reducing or managing the deterioration in health status in patients with a degree of long-term dependency. Main results and findings from a questionnaire submitted to countries on sources and methodology for long-term care spending can be found as an annex;
• home-based care, which means the medical, ancillary and nursing services that are consumed by patients at their home and involve the providers' physical presence;
• ancillary services (non-specified by function), which means the healthcare or long-term care related services non-specified by function and non-specified by mode of provision, which the patient consumes directly, in particular during an independent contact with the health system and that are not integral part of a care service package, such as laboratory or imaging services or patient transportation and emergency rescue;
• pharmaceuticals and other medical non-durable goods (non-specified by function), which means pharmaceutical products and non-durable medical goods intended for use in the diagnosis, cure, mitigation or treatment of disease, including prescribed medicines and over-the-counter drugs, where the function and mode of provision are not specified;
• therapeutic appliances and other medical goods (non-specified by function), which means medical durable goods including orthotic devices that support or correct deformities and/or abnormalities of the human body, orthopaedic appliances, prostheses or artificial extensions that replace a missing body part, and other prosthetic devices including implants which replace or supplement the functionality of a missing biological structure and medico-technical devices, where the function and the mode of provision are not specified;
• preventive care, which means any measure that aims to avoid or reduce the number or the severity of injuries and diseases, their sequelae and complications; Preventive care includes interventions for both individual and collective consumption;
• governance, and health system and financing administration, which means services that focus on the health system rather than direct healthcare, direct and support health system functioning, and are considered to be collective, as they are not allocated to specific individuals but benefit all health system users.

Finally, current expenditure on healthcare means the final consumption expenditure of resident units on healthcare goods and services, including the healthcare goods and services provided directly to individual persons as well as collective healthcare services.

Health care financing schemes

‘Healthcare financing schemes’ means types of financing arrangements through which people obtain health services, including both direct payments by households for services and goods and third-party financing arrangements. The following main items are defined as:

• government schemes, which means healthcare financing schemes whose characteristics are determined by law or by the government and where a separate budget is set for the programme and a government unit that has an overall responsibility for it;
• compulsory contributory health insurance scheme, which means a financing arrangement to ensure access to healthcare for specific population groups through mandatory participation determined by law or by the government and eligibility based on the payment of health insurance contributions by or on behalf of the individuals concerned;
• social health insurance schemes, which means a financing arrangement to ensure access to healthcare for specific population groups through mandatory participation determined by law or by the government, and eligibility based on the payment of health insurance contributions by or on behalf of the individuals concerned;
• compulsory private insurance schemes, which means a financing arrangement to ensure access to healthcare for specific population groups through mandatory participation determined by law or by the government and eligibility based upon the purchase of a health insurance policy;
• voluntary health insurance schemes, which means schemes based upon the purchase of a health insurance policy, which is not made compulsory by government and where insurance premiums may be directly or indirectly subsidised by the government;
• non-profit institutions financing schemes, which means non-compulsory financing arrangements and programmes with non-contributory benefit entitlement that are based on donations from the general public, the government or corporations;
• enterprise financing schemes, which means primarily arrangements where enterprises directly provide or finance health services for their employees without the involvement of an insurance-type scheme;
• household out-of-pocket payment, which means a direct payment for healthcare goods and services from the household primary income or savings, where the payment is made by the user at the time of the purchase of goods or the use of the services. A report summarising some of the main findings from a supplementary questionnaire on sources and methodology for OOP payments and current practices of OOP reporting in SHA can be found as an annex;
• rest of the world financing schemes, which means financial arrangements involving or managed by institutional units that are resident abroad, but who collect, pool resources and purchase healthcare goods and services on behalf of residents, without transiting their funds through a resident scheme.

Health care providers

Healthcare providers means the organisations and actors that deliver healthcare goods and services as their primary activity, as well as those for which healthcare provision is only one among a number of activities. The following main items are defined as:

• hospitals, which means the licensed establishments that are primarily engaged in providing medical, diagnostic and treatment services that include physician, nursing and other health services to inpatients and the specialised accommodation services required by inpatients and which may also provide day care, outpatient and home healthcare services;
• residential long-term care facilities, which means establishments that are primarily engaged in providing residential long-term care that combines nursing, supervisory or other types of care as required by the residents, where a significant part of the production process and the care provided is a mix of health and social services with the health services being largely at the level of nursing care in combination with personal care services;
• providers of ambulatory healthcare, which means establishments that are primarily engaged in providing healthcare services directly to outpatients who do not require inpatient services, including both offices of general medical practitioners and medical specialists and establishments specialising in the treatment of day-cases and in the delivery of home care services;
• providers of ancillary services, which means establishments that provide specific ancillary type of services directly to outpatients under the supervision of health professionals and not covered within the episode of treatment by hospitals, nursing care facilities, ambulatory care providers or other providers;
• retailers and other providers of medical goods, which means establishments whose primary activity is the retail sale of medical goods to the general public for individual or household consumption or utilisation, including fitting and repair done in combination with sale;
• providers of preventive care, which means organisations that primarily provide collective preventive programmes and campaigns/public health programmes for specific groups of individuals or the population-at-large, such as health promotion and protection agencies or public health institutes as well as specialised establishments providing primary preventive care as their principal activity;
• providers of healthcare system administration and financing means establishments that are primarily engaged in the regulation of the activities of agencies that provide healthcare and in the overall administration of the healthcare sector, including the administration of health financing;
• rest of the economy means other resident healthcare providers not elsewhere classified, including households as providers of personal home health services to family members, in cases where they correspond to social transfer payments granted for this purpose as well as all other industries that offer healthcare as a secondary activity;
• rest of the world providers means all non-resident units providing healthcare goods and services as well as those involved in health-related activities.

Revenues of financing schemes

Revenues of financing schemes provide information on the funding of health expenditures: how the revenues financing the different schemes are raised and from what sources they are financed. The identification of revenues can also identify the private from the public part funding. A Revenue is classified according to the types of transactions through which the financing arrangements derive their income. The following main items are defined as:

• transfers from government domestic revenues: funds allocated from government domestic revenues for health purposes;
• transfers distributed by government from foreign origin: transfers originating abroad that are distributed through the general government;
• social insurance contributions: receipts either from employers on behalf of their employees or from employees, the self-employed or non-employed persons on their own behalf that secure entitlement to social health insurance benefits;
• compulsory prepayment: compulsory private insurance premiums paid from the individuals/households, the employers or institutional units to the benefit of compulsory health insurance schemes;
• voluntary prepayment: voluntary private insurance premiums received from the insuree or other institutional units on behalf of the insuree to secure entitlement to benefits of the voluntary health insurance schemes;
• other domestic revenues n.e.c: domestic revenues of financing schemes not included in the above-mentioned categories;
• direct foreign transfers: revenues from foreign entities directly received by the health financing schemes.

Data are presented in 4 summary (one-dimensional) tables and 4 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)
• Revenues of health care financing schemes (ICHA-FS)

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 the different types of services and goods are financed;
• HP x HF: Health care expenditure by provider and by financing scheme: data on which health care provider and under which particular financing scheme the services and goods are purchased from;
• HF x FS: Revenues of health care financing schemes by health care financing scheme: data on the sources of revenues for each financing scheme.

The economy of a country is the outcome of the activity of a very large number of units which carry out numerous transactions of various kinds for purposes of production, finance, insurance, redistribution and consumption. The units and groupings of units used in the accounts must be defined with reference to the kind of economic analysis for which they are intended. To analyse the process of production, it is essential to select units which bring out relationships of a technico-economic nature; to analyse flows affecting financial transactions it is essential to select units which make it possible to study relationships among economic agents.

Statistical and administrative sources refer usually to institutional units active in providing health (care) services to the population. In the description of the financing of health care, the units mainly refer to those involved in the process of paying for the services delivered for consumption. Expenditure refers to the payments related to final consumption of all goods and services by the domestic population (in the majority of countries, health care services provided to foreigners cannot be separated and are included in the domestic consumption).

In the health care expenditure data collection three approaches are possible. Data collection can be built starting either from the financing, or from the provider side or from the functional side. Depending on the information source available various elements can be used as statistical unit. It may be an observation unit on which information is received and statistics are compiled, or an analytical unit which statisticians create by splitting or combining observation units with the help of estimations or imputations, in order to supply more detailed and/or homogenous data than would otherwise be possible.

The data aim at providing a complete overview of expenditure on health care goods and services consumed by the domestic population and produced by providers of health care, from whichever source this consumption is financed.

European Union Member States, EFTA countries (Norway, Liechtenstein, Iceland, Switzerland), Bosnia and Herzegovina and the Republic of Serbia provide data for Health Care Expenditure.

According to the Regulation, the first mandatory transmission was for the reference year 2014. Historical data, subject to gentleman's agreement, was also reported by many countries. However, the availability varies across countries and classifications.

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)

EU aggregates are available from reference year 2014 and for subsequent years when all EU Member States data is disseminated.

Calendar year

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 Organisation (WHO) and the Organization of Economic Co-operation and Development (OECD).

Regulation (EC) No 223/2009 on European statistics (recital 24 and Article 20(4)) of 11 March 2009 (OJ L 87, p. 164), stipulates the need to establish common principles and guidelines ensuring the confidentiality of data used for the production of European statistics and the access to those confidential data with due account for technical developments and the requirements of users in a democratic society.

Not applicable

Not applicable

Not applicable

In line with the Community legal framework and the European Statistics Code of Practice, and respecting professional independence, Eurostat disseminates European statistics on Eurostat's website (see item 10 - 'Accessibility and clarity') 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. 

Data is disseminated country by country when the data has been fully validated by Eurostat.

Not available

Statistics Explained; data are also used in various other publications.

Please consult free data on-line

Not applicable

None

Please consult:

• A System of Health Accounts 2011,
• the national quality reports,
• the methodological information per country available in Annex (updated every year).

National quality reports have been disseminated in accordance with article 8 of the Regulation (EC) No 1338/2008 of the European Parliament and of the Council of 16 December 2008 on Community statistics on public health and health and safety at work.

Accordingly, national quality reports have been published at the latest on 27 March 2020.

Eurostat and the National authorities responsible for SHA data collection are working to ensure that the statistical practices used to compile national health accounts are in compliance with the SHA methodological requirements, as well as that good practices in the field are being followed, according to the methodology underlined in the SHA 2011 Manual.

The quality of the data is subject to the way, in which health care provision is organised in countries, and which information is available to and collected by the respective institutions.

Member States and Eurostat are continuously working to maintain and improve the quality and the comparability of SHA data. In line with Article 8 of the Regulation (EC) No 1338/2008 of the European Parliament and of the Council of 16 December 2008 on Community statistics on public health and health and safety at work, Member States have transmitted to Eurostat a report on the quality of their data (individual reports are available at the top of the page). A consolidated quality report on healthcare expenditure and financing statistics — 2020 edition has also been published.

Health accounts are increasingly expected to provide inputs (along with other statistical information) into improved analytical tools to monitor and assess health system performance. One high priority is to develop reliable, timely data that is comparable both across countries and over time. This is indispensable for tracking trends in health spending and the factors driving it, which can in turn be used to compare it across countries and to project how it will grow in the future.

Health accounts are thus used in two main ways: internationally, where the emphasis is on a selection of internationally comparable expenditure data, and nationally, with more detailed analyses of health care spending and a greater emphasis on comparisons over time. Health accounts are crucial for both of these.

Not available

All the information as required by the Regulations (see point 6.1) has been disseminated by Eurostat.

Accuracy of SHA data is linked to and depends on the accuracy of the data received from the countries. Data sources are mainly administrative and register-based data, only a small percentage of the figures come from surveys or other means. Accordingly, for SHA data collection, accuracy deals with problems of coverage as the main possible source of errors. For the detailed information on sources used by countries see the Methodological information per country in the Annex.

Not applicable

Not applicable

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 N shall be transmitted to Eurostat by 30 April N+2. Preliminary data for the year N+1 is transmitted by some Member States on a voluntary basis.

Nearly all countries participating to SHA data collections are currently able to meet the legal deadlines for transmissions of data and metadata (see paragraph 14.1, as reference).

The comparability is insured by the application of common definitions (System of Health Accounts SHA2011).

In Eurostat consolidated quality report (see in Annex), an overview of comparability between countries is available.

By using a common framework, the System of Health Accounts SHA2011, data can be comparable over time.

For countries that provide only short time series it is difficult to determine the comparability over time.

More detailed information on per-country comparability issues is provided in the Methodological Information of each country in the Annex.

None

The data are consistent

Not available

The general Eurostat revision policy applies to this domain.

National data are revised according to national schedules (see methodological information per country in the Annex and in the national quality reports). 

In general, methodological improvements apply to the total time span for most countries, while punctual data corrections could occur (new data sources, updated statistical information based on surveys or administrative sources, errors discovered in the data compilation). When a new source of information is identified and used, the data for previous years are revised, if possible. The revisions of the National Accounts data could also trigger possible revisions.

Revisions are applied to Eurostat's online database as soon as they become available to Eurostat.

All reported errors (once validated) result in corrections of the disseminated data.

Reported errors that are deemed to be significant are corrected in the disseminated data as soon as the correct data have been validated. Corrections for other errors are carried out in connection with the regular scheduled data dissemination.

Data are only published once they are deemed to be sufficiently complete for all data providers.

New data are only used to update disseminated data if provided according to the provision schedule set by Eurostat, or in the case of reported errors.

In case a country sends new data for previous years the data set for this country is updated.

Data are collected through the joint health accounts questionnaire (JHAQ) that countries submit to Eurostat during the annual data collection exercise. For compiling the JHAQ, countries use data from their national health account registries, which comprise, but are not limited to, data that are based on different statistical sources:

• specific surveys performed for healthcare activities;
• household budget survey;
• administrative sources (registers);
• data collected for the purpose of national accounts;
• data information systems available in health (and other) ministries / departments as well as other agencies involved in health care.

The different sources may lead to differences in the coverage of time series, data validity, reliability and comparability. Furthermore, it may not always be possible to have the health care system being consistently defined across data sources.

For expenditure calculated as share of GDP, the national GDP in euro as available in the EUROSTAT database is used. Expenditure per capita is calculated using the corresponding national (average) population data. Expenditure data expressed in PPS is calculated using the corresponding national data as collected by the National Accounts department in EUROSTAT.

Please note that some of the data sources used nationally may not have been initially intended to be used for statistical purposes, and that the initial purpose of a data source may differ across countries. Both facts may influence the comparability of results.

Annual

Data are collected through the joint health accounts questionnaire (JHAQ) that countries submit to Eurostat during the annual data collection exercise.

Consistency checks are carried out in co-operation with OECD and WHO health accountants. Principally, the consistency of all the subtotals at all levels of aggregation are checked against the relevant totals. All identical items are checked for consistency across the various tables. Plausibility of values is checked (as far as possible) against documentation provided in the metadata and, if possible, against other countries. Also the development in time is checked for consistency (e.g. against the metadata provided by the country).

All transactions are to be calculated on accrual principles, meaning that the expenditure data relate to all transactions or activities carried out during the calendar year for which data are reported, irrespective of the date of payment for these services.

No adjustment is needed