Statistics Denmark 

Government Finances

Sankt Kjelds Plads 11, 2100 København Ø, Denmark

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:

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.

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).

Denmark.

2010 - 2023

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: 2010-2023.

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.

All legal requirements are met. The statistics is published at a level of aggregation which does not require additional discretion.

The publication date for health care expenditures can be found in the statistical programe for Statistics Denmarks. The date is confirmed in the weeks prior to the national publication and international transmission.

Please refer to the Release calendar - Eurostat (europa.eu) and Scheduled Releases - Statistics Denmark which are publicly available on the Eurostat’s and Statistics Denmark's websites.

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.

Data is often used by the media in Denmark. Here, both data is used for international comparisons, but also with a focus on specific areas such as COVID-19 and spending on pharmacueticals. 

Along with the national publication of data the statistic is used for the publication "New" from Statistics Denmark: Health care expenditures. 

The statistic is published in the StatBank under the in table:

• SHA1: Health care expenditures by function, provider, financing scheme and price unit

Not applicable.

Data is transmitted to Eurostat, who forwards data to OECD and WHO. Transmitted data can be found in the international databases at OECD, Eurostat and WHO.

The statistics is produced in compliance with the reference manual A System of Health Accounts - SHA 2011.

Statistics Denmark follows the recommendations on organisation and management of quality given in the Code of Practice for European Statistics (CoP) and the implementation guidelines given in the Quality Assurance Framework of the European Statistical System (QAF). A Working Group on Quality and a central quality assurance function have been established to continuously carry through control of products and processes.

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 statistic reflects the consumption expenditure on health care system in Denmark and is published annually four months after the end of the reference period. Data will be revised back to year t-4, thus relevant and meet users' needs. The statistics is made in accordance with SHA2011 definitions and classifications and is presented nationally with Danish health terminology, which results in an easy understanding of the data presented. The statistics is consistent and international comparable with countries within OECD and Eurostat throughout the entire time period.

The overall accuracy of the statistics is considered to be high, as the primary data sources is constituted by the general government finances. However, there are uncertainty associated with the use of a few supplementary sources such as the Household Budget Survey especially for the most recent reference year (t-1) as data sources will not be final or even availble at the time of transmission. Here data will be partly based on projections of minor datasources. Moreover, misclassifications can occur as it can be difficult to determine whether some areas are within the scope of the SHA. This implies that the uncertainty increases with the level of detail.

The accuracy is therefore highest for the overall SHA-categories and for year t-2 and before.

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

Data regarding user satisfaction is not gathered at the moment.

 Health care fincancing schemes:

Health care functions: 

Health care providers:

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 overall accuracy of the statistics is relatively high, as the primary data source is constituted by the general government finances. Distribution weights are applied to general government finance accounts to get more detailed information, which, however, add a degree of uncertainty. The private part of the statistics concerning household out-of-pocket payments may be subject to uncertainty due to the use of the Household Budget Survey. Moreover, the latest year will be subject to further uncertainty as projections are used for individual sources.

Not relevant for this statistic.

Misclassification within the SHA2011 framework can lead to systematic uncertainty. Misclassification is attempted to be reduced by a detailed review of each account from the general government and after thorough research applied with SHA-codes. Furthermore, changes can occur in the lineup of annual reports, which can lead to over or underestimation of the health care expenditures.

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.

Statistics Denmark complies with the Commission Regulation 2021/1901 transmission deadlines. SHA Data is send annually to Eurostat by 30 April. 

Not applicable at the national level

In 2020 a new National Patient Register came into force, which has lead to a methological change in the definition of inpatient and outpatient treatment. Prior to 2020 inpatient treatment was defined directly from the National Patient Register, whereas in the new register no such variable exists, however the status of treatment is now defined from the number of hours of a stay. A stay of less than 12 hours is considered as outpatient, while a stay pf more than 12 hours leads to an inpatient stay. This leads to a break in timeseries from 2020 for the levels of item HC.1.3.1 and HC.1.1. Otherwise the statistics is compiled following the same method in the entire time period from 2010. 

The majority of data originates from the general government finances, which are included in the National Accounts, because there is a link to this. The difference between the inventories is caused by differences in the SHA classification and the concepts of National Accounts. Furthermore, the Household Budget Survey is used as an input for household consumption of health care goods and services, because there also is a link to this. Moreover, the Household Budget Survey is included as input to the National Accounts.

The statistic is internally consistent, which is ensured by consolidations of transactions and application of the concepts of national accounts.

There is no direct reporting burden as the information mainly is obtained by accounts for the central and local governments along with annual reports form various relevant websites. We estimate the use of 0.5 to 1 full-time equivalent to complete the JHAQ data collection at Statistics Denmark. 

Statistics Denmark revises published figures in accordance with the Revision Policy for Statistics Denmark. The common procedures and principles of the Revision Policy are for some statistics supplemented by a specific revision practice.

The statistic follows the revision policy of the national accounts, where years t-2, t-3 and t-4 are recalculated simultaneously with the calculation of year t-1. The revisions of previous years are published simultaneously with year t-1.

The statistics is compiled using a number of internal and external sources.

Internal sources

• Data extracts from Statistics Denmark's internal database DIOR (database for integrated public accounts), which stores the accounting information from the central and local governments.
• Data deliveries from the office of National Accounts in Statistics Denmark about the final consumption expenditure of households on health care goods and services. Data from this is published in Statbank's table NAHC23 for year t-3 in jun.
• Data from the Household Budget Survey are used as weights to split between general practitioners, dentists, physiotherapists etc.
• Data from table AED022 and AED03 on the number of visited hours for personal and practical help in own home and nursing homes, respectively along with table SYGUS2 on public expenditures to psychiatry. Data from table AED022 and AED03 are used to calculate a distribution key.

External sources

• Data deliveries from the Danish Health Data Authority based on DRG-grouped National Patient Register to split expenses in somatic hospitals between inpatient and outpatient curative care. In addition, data from the Register of Pharmaceutical sales are also provided.
• Data from publicly available annual reports from the patient organizations: Danish Cancer Society, Gigtforeningen, Hjerteforeningen samt Health Insurance ´danmark´ and Statens Serum Institut.
• Key figures from F&P concerning health insurance schemes.
• Data delivery from the JRCC Joint Rescue Center regarding the cost of ambulance flights.
• Extraordinary for 2020-2022, COVID-19-related information have been collected from the local governments and Statens Serum Institut. In addition, specific delivery is received for the treatment costs of COVID-19 patients from the Danish Health Data Authority based on DGR-grouped LPR3 data. From 2023 specific information on COVID-19-related activities is no longer collected, as COVID-19 no longer is considered a socially critical disease thus included as a part of 'normal' health activity.

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.

At the national level the majority of data is collected by data extractions from Statistics Denmark's internal database DIOR (database for integrated public accounts) and by internal data deliveries from the office of National accounts. Data extractions from DIOR are conditioned on the SHA2011 definition of consumption. By an in depth examination of the central government accounts §16 The Danish Ministry of Health and the local government accounts a code list have been prepared which determines all relevant consumption expenditures from the public accounts within the scope of SHA2011. Furthermore, a part of data is collected from supplementary sources from The Danish Health Data Authority, various patient organizations and health insurance "danmark" and F&P.

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)

At the national level data is validated at macro levels by controls of time series and other reasonableness check with the statistics of general government finances. 

When the collection of data is complete, data is classified according to the SHA2011 manual. This implies that for each consumption expenditure, an associated health function, provider and financing scheme is coded. The classification of primary data takes place on a very detailed level, where the main account level for the central government as well as the function and grouping level for local governments are coded. The classification is made through a number of processes:

1. Data from general government finances are compared with previous years and all previous classifications are transferred to recent year.
2. New accounts are classified manually according to the SHA2011.
3. A number of cases are then applied. These cases provide additional information, which results in partial reclassification of SHA2011 coding from the first two processes. The reclassification primarily concerns expenses at the local government levels as there are several accounts that contain different SHA categories. The cases impose distribution keys such as the distribution of expenses for personal and practical help or the distribution between psychiatrists and other specialists.

Estimation methods: 

For the recent year, annual reports or relevant information in order to calculate the specific cases are not always available. Thus, information from previous years will be projected by either previous growth rates or projections from other sources depending on the data basis.

After the classification of data is completed, data is integrated, validated and transmitted.

Not relevant.

• In 2020 a new version of the Danish National Patient Register (LPR3) were relased. This version lead to a methological change in the definitions of inpatient and outpatient care at hospitals thus leading to a break in timeseries between 2019 and 2020 on the functions 1.1 Inpatient curative care and 1.3.1 General outpatient curative care.
• From 2023 the COVID-19-related costs are no longer seperated from the total health care expenditures as of February 2022 Denmark no longer considered COVID-19 as a socially critical disease hence all activies concerning test and vaccinations have either been reduced significantly or complete eliminated. Treatment of COVID-19-patient will be included in the expenditure related to HC1.3.1/HP1.1