State Data Agency (Statistics Lithuania)

Social Protection, Health, Education and Culture statistics division

State Data Agency (Statistics Lithuania)
29 Gedinimo Ave., Vilnius, Lithuania
LT-01500

Health care expenditure quantifies the economic resources dedicated to health functions, excluding capital investment. Healthcare expenditure concerns itself primarily with healthcare goods and services that are consumed by resident units, irrespective of where that consumption takes place (it may be in the rest of the world) or who is paying for it. As such, exports of healthcare goods and services (to non-resident units) are excluded, whereas imports of healthcare goods and services for final use are included.
Health care expenditure data provide information on expenditure in the functionally defined area of health distinct by provider category (e.g. hospitals, general practitioners), function category (e.g. services of curative care, rehabilitative care, clinical laboratory, patient transport, prescribed medicines) and financing scheme (e.g. social security, private insurance company, household). For the collection of the data on health care expenditure the System of Health Accounts (SHA) and its related set of International Classification for the Health Accounts (ICHA) is used. SHA sets out an integrated system of comprehensive and internationally comparable accounts and provides a uniform framework of basic accounting rules and a set of standard tables for reporting health expenditure data. The System of Health Accounts - SHA 2011  is a statistical reference manual giving a comprehensive description of the financial flows in health care.

It provides a set of revised classifications of health care functions, providers of health care goods and services and financing schemes. The SHA is currently used as a basis for a joint data collection by OECD, Eurostat and WHO on health care expenditure. The manual sets out in more detail the boundaries, the definitions and the concepts of health accounting – responding to health care systems around the globe with very different organisational and financing arrangements.

Accounting period: Health expenditure and financing data pertain to the calendar year (1 January to 31 December).

Healthcare expenditure is recorded in relation to the international classification for health accounts (ICHA) defining:

• healthcare expenditure by financing schemes (ICHA-HF) — which classifies the types of financing arrangements through which people obtain health services; health care financing schemes include direct payments by households for services and goods and third-party financing arrangements;
• healthcare expenditure by function (ICHA-HC) — which details the split in healthcare expenditure following the purpose of healthcare activities — such as, curative care, rehabilitative care, long-term care, or preventive care;
• healthcare expenditure by provider (ICHA-HP) — which classifies units contributing to the provision of healthcare goods and services — such as hospitals, residential facilities, ambulatory health care services, ancillary services or retailers of medical goods.

1. Household individual consumption on health, including the collective consumption with two exceptions:

1. Occupational health care (intermediate consumption within establishments) minus an estimated share of occupational health in health providers’ and other medical industries net administration;
2. “Remunerated” unpaid household production in the form of transfer payments (social benefits in cash) for home care of sick, disabled and elderly persons provided by family members.

SHA 2011 Manual recommends following the standard System of National Account (SNA) rules for drawing the production boundary of health care services, albeit with two notable exceptions:

• Occupational health care is included in the national totals of health care spending. In SNA, this item is recorded as ancillary services and part of intermediate production of enterprises and;
• Part of the cash transfers to private households for care givers of home care for the sick and disabled are treated as the paid household production of health care.

2. Health care financing schemes:

• HF1 Government schemes and compulsory contributory health care financing schemes;
• HF2 -voluntary health care payment schemes;
• HF3 - Household out-of-pocket payment;
• HF4 - rest of the world financing schemes.

3. NACE rev. 2, section Q, human health and social work activities.

SHA concept is the consumption of health care goods and services.

Health care statistics describe the process of providing and financing health care in countries by referring to health care goods and services, its providers and financing. For the collection of the data on health care expenditure the System of Health Accounts (SHA) and its related set of International Classification for the Health Accounts (ICHA) is used. SHA is a tri-axial system in which the financing, provision and consumption dimensions are covered by the ICHA (International Classification for Health Accounts): Health Care Functions (HC), Health Care Providers (HP), Health Care Financing Schemes (HF).

Data are presented in 3 summary (one-dimensional) tables and 3 cross-classification tables (2-dimensional tables).

Summary tables provide data on:

• Current expenditure by provider (ICHA-HP);
• Current expenditure by function (ICHA-HC);
• Current expenditure by financing scheme (ICHA-HF).

Cross-classification tables refer to:

• HC x HP: Health care expenditure by function and provider: data on which type of health care goods and services are supplied by which health care provider;
• HC x HF: Health care expenditure by function and by financing scheme: data on how are the different types of services and goods financed;
• HP x HF: Health care expenditure by provider and by financing scheme: data on from which health care provider and under which particular financing scheme are the services and goods purchased.

The classifications and definitions presented in the SHA 2011 manual are to be followed. Additional guidelines and material useful for compilers are also available at this address.

Commission Regulation (EU) 2021/1901, and Commission Regulation (EU) 2015/359 previously in force, concern the collection of data on "current expenditure on healthcare" which is defined as the "final consumption expenditure of resident units on health care goods and services".

There is a very close relationship between the concept of "final consumption expenditure" as defined in the System of Health Accounts (SHA) and in National Account and, as a consequence, also between the underlying economic transactions as recorded in the two accounting frameworks.

In National Accounts there are two types of statistical units: institutional units and local kind-of-activity units (KAU). A local KAU groups all the parts of an institutional unit in its capacity as producer which are located in a single site. A local KAU belongs to one and only one institutional unit.

SHA uses the same two types of units for data compilation.

Local KAUs operating as providers of healthcare goods and services to resident units are statistical units in SHA.

Also transactions by institutional units are recorded in SHA, in which framework institutional units are also referred to as "financing agents". More precisely, SHA financing agents are institutional units that manage one or more financing schemes. The transactions are executed by the financing agents, according to the rules of the financing schemes.

Financing agents serve as key statistical units in producing national health accounts. While financing schemes are the key units for analysing how the consumption of health care goods and services is financed, the data concerning the relevant transactions are collected either from the financing agents that operate the different financing schemes or from the providers.

The concept of "healthcare financing schemes" in SHA is an application and extension of the concept of "social protection schemes" defined by the European System of Social PROtection Statistics (ESSPROS):  "a distinct body of rules, supported by one or more institutional units, governing the provision of social protection benefits and their financing ...". The social protection scheme is the statistical unit in ESSPROS. It is an analytical unit that allows describing the complete structure of the social protection financing system:  expenditure and receipts.

According to SHA Manual 2011, "the key concepts for describing the structure of the health care financing system are based on measuring: (a) the expenditure of health care financing schemes, under which goods and services are purchased directly from health care providers, on the one hand, and (b) the types of revenues of health care financing schemes, on the other hand.  

Commission Regulation (EU) 2021/1901  and (prior Commission Regulation (EU) 2015/359) limits its scope to the collection of data on the expenditure of health care financing schemes.

The statistical population is all providers of health care services and goods in the country.

The whole economic territory of the country.

Health care revenues from 2014, health care expenditure from 2007.

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: 2022.

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;

Commission Regulation (EU) 2021/1901 of 29 October 2021 implementing Regulation (EC) No 1338/2008 of the European Parliament and of the Council as regards statistics on healthcare expenditure and financing.

The exchange of statistical data required for the implementation of the Official Statistics Program is defined in Article 17 of the Republic of Lithuania Law on Official Statistics and State Data Governance. Statistical information and metadata are provided to Eurostat, World Health Organization (WHO) and Organisation for Economic Co-operation and Development (OECD) through a joint questionnaire.

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

In the process of statistical data collection, processing and analysis and dissemination of statistical information, State Data Agency fully guarantees confidentiality of the data submitted by respondents (households, enterprises, institutions, organisations and other statistical units), as defined in the Confidentiality policy guidelines of Statistics Lithuania.

Statistical Disclosure Control Manual, approved by Order No DĮ-26 of 19 January 2024 of the Director General of State Data Agency;

The State Data Governance Information System Data Security Regulations and Rules for the Secure Management of Electronic Information in the State Data Governance Information System, approved by Order No DĮ-202 of 27 August 2021 of the Director General of State Data Agency.

Not applicable.

Please refer to the Release calendar - Eurostat (europa.eu) and publicly available on the Eurostat’s website.

In line with the Community legal framework and the European Statistics Code of Practice Eurostat disseminates European statistics on Eurostat's website (see item 10 - 'Accessibility and clarity') respecting professional independence and in an objective, professional and transparent manner in which all users are treated equitably. The detailed arrangements are governed by the Eurostat protocol on impartial access to Eurostat data for users.

Annual.

Not available.

Annual statistical information is published in the publication "Lithuania in Figures"

Statistical indicators are published in the Official Statistics Portal Indicators database (Population and social statistics -> Health -> Healthcare revenues and expenditure).

The Indicators Database page is for viewing and analyzing statistical information. For more information on the Indicators Database, see the Database of Indicators User Guide.

State Data Agency may, on the basis of contracts concluded with higher education institutions or research institutes, provide statistical data to researchers of these higher education institutions and research institutes to carry out specific statistical analyses for research purposes. Statistical data are provided in accordance with the provisions specified in the Description of Procedure for Data Depersonalisation and Pseudonymisation. More information is available on the Official Statistics Portal, in the section Data Provision.

Statistical information is published in the Eurostat’s database, WHO database, OECD database.

Statistical information can also be provided upon individual requests (more information is available on the Official Statistics Portal, in section Services).

Methodological documents are published in the Official Statistics Portal, section Health. 

The Manual of the System of Health Accounts was used to compile statistical information (A System of Health Accounts).

A separate Quality report is not prepared. The main information on health expenditure data are provided in the standard metadata file mentioned in point 10.6.

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 as well as  ESS Quality Assurance Framework. Procedures are in place to plan and monitor the quality of the health care expenditure statistical production process.

In 2007, a quality management system, conforming to the requirements of the international quality management system standard ISO 9001, was introduced at State Data Agency. The main trends in activity of State Data Agency aimed at quality management and continuous development in the institution are established in the Quality Policy. Monitoring of the quality indicators of statistical processes and their results and self-evaluation of statistical survey managers is regularly carried out in order to identify the areas which need improvement and to promptly eliminate the shortcomings.

The main users of statistical information are state and municipal institutions and bodies, the WHO, the OECD, Eurostat, the media, representatives of business and science, and students, whose needs are satisfied without a breach of the confidentiality principle. Statistical information is used to analyze changes in health care income and expenditure, health system developments and international comparisons.

From 2005, user opinion surveys have been conducted on a regular basis. Official Statistics Portal traffic is monitored, website visitor opinion polls, general opinion poll on the products and services of State Data Agency, target user group opinion polls and other surveys are conducted. In 2007, the compilation of a user satisfaction index was launched. The said surveys are aimed at the assessment of the overall demand for and necessity of statistical information in general and specific statistical indicators in particular.

For more information on user surveys and their results, see User Surveys section on the State Data Agency website.

State Data Agency transmits the data to Eurostat in compliance with the Commission Regulation 359/2015.

State Data Agency doesn't conduct a special survey for the Health Expenditure data; therefore, an accuracy of the results very much depends on the overall quality of data sources used. Primary data from administrative sources and statistical surveys are classified using ICHA codes and aggregated; in some cases estimation methods are applied. The results are analysed taking into account several aspects –changes of legal base developing the health system,  changes in structure and scope of services of particular provider, information from different sources about the particular item of accounting.  Lacks in accuracy are observed in the fields where appropriate data sources for specific categories are missing or are not comprehensive enough. However, the analysis of new potential sources that could supplement existing data is performed continuously.

Not applicable.

No sample estimates are used. Coverage error is based on the lack of data or insufficient comprehensiveness of it in the available data sources.

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.

State Data Agency (Statistics Lithuania) complies with the Commission Regulation 2021/1901 transmission deadlines. State Data Agency usually sends SHA data annually to Eurostat by 30 April. The data for 2022 were transmitted ahead of schedule, in February.

Statistical information is comparable across the EU.

Data according to SHA 2011 is available for the years 2006–2022 and comparable over this time frame.
Breaks in time series resulting from methodological changes:

The values of the statistical indicators “Health care expenditure of general government and compulsory contributory health insurance schemes” (according to the System of Health Accounts) and “General government expenditure on health care” (according to COFOG) are not compatible due to different coverage and calculation methodologies. Part of the expenditure included in "General government expenditure on health care" (according to COFOG) according to the Health Accounts System methodology is classified as health-related functions or not considered as health care, therefore from the current health care expenditure is excluded, but the part of long-term care expenditure covered by the Social Protection Function (according to COFOG) is included.

Statistics on health care financing programs, service and goods providers, and health care functions are internally coherent. Data on health care funding programs, providers and functions at lower classification levels are aggregated and the same result is produced.

20 thousand euros were allocated for the statistical work in 2023.

Administrative data and statistical survey data are used. In this case, there is no additional statistical reporting burden on respondents. 

The revision policy applied by State Data Agency is described in the Description of Procedure for Performance, Analysis and Publication of Revisions of Statistical Information.

Reasons for revision. Planned revisions. Revisions may be carried out in the event of significant errors, changes in classifications, updating of methodologies, additions or revisions to the statistical data used to calculate the value of a statistical indicator, the emergence of new sources of statistical data, etc.

Methods. The preliminary annual statistical information is revised/adjusted following the recommendations of the OECD, WHO and Eurostat expert group at the time of validation of the data: adjustments are made to the attribution of expenditure categories to health care functions, the validity of the breakdown of expenditures by function, and the verification of the primary source data and the calculations derived from them.

Detail and cyclicality. The publication of annual statistical information for the new period is followed by a revision/adjustment of the health expenditure statistics for the previous period. Derivatives (health expenditure as a share of gross domestic product, health expenditure per capita) are recalculated after revisions of gross domestic product and population.

Comparability. Comparable annual statistical information on health expenditure has been published since 2007 and on income since 2014.

Revisions calendar. Revisions shall be carried out in accordance with the Statistical Information Revisions Calendar. The approved calendar of revisions of the planned statistical indicators for the current year, which is integrated into the Official Statistics calendar, is published on the Official Statistics portal. In accordance with the Official Statistical Calendar, the annual statistical information is revised once a year. Other possible revisions may be made according to circumstances (administrative data disruptions, prior estimates, etc.).

Publication of results to users. The revised health expenditure statistics shall be published on the Official Statistics Portal (OSP). Revised/revised statistical information is indicated in the OSP Indicators Database by the special symbols 'revised and recalculated data' and users may be informed of the revisions by means of special footnotes.

Statistical data sources are data from statistical surveys and administrative sources. Statistical survey data used: the Survey of Personnel of Health Care Institutions (Institute of Hygiene), Survey of Social and Cultural Services Enterprise (State Data Agency), Survey of Social Services (State Data Agency), Information on Social Protection Receipts and Expenditure (according to ESSPROS methodology) (State Data Agency), Survey of Trade Enterprises (State Data Agency), Survey on the Composition of Retail Trade Turnover (State Data Agency). Data from administrative sources used: the Ministry of Health of the Republic of Lithuania, State Sickness Fund under the Ministry of Health, Ministry of Finance of the Republic of Lithuania, State Social Insurance Fund Board under the Ministry of Social Security and Labor, State Tax Inspectorate under the Ministry of Finance of the Republic of Lithuania, Ministry of the Interior of the Repiublic of Lithuania, Ministry of Justice of the Republic of Lithuania, the Lithuanian Armed Forces, the Center of Registers.

Annual.

Data are collected through the joint health accounts questionnaire (JHAQ) that is submitted to Eurostat during the annual data collection exercise. There is a voluntary deadline to send the JHAQ questionnaire for the calendar year T by the 31st of March T+2. The joint health accounts questionnaire (JHAQ) is coordinated in agreement with the World Health Organisation (WHO) and the Organization of Economic Co-operation and Development (OECD). These three international organisations are known collectively as the International Health Accounts Team (IHAT). Data are submitted to Eurostat based on Commission Regulation (EU) 2015/359 of 4 March 2015 implementing Regulation (EC) No 1338/2008 of the European Parliament and of the Council as regards statistics on healthcare expenditure and financing, until reference year 2020. As of reference year 2021 onwards Commission Regulation (EU) 2021/1901 of 29 October 2021 implementing Regulation (EC) No 1338/2008, is in force.

The 2023 JHAQ includes a number of features which allow national data correspondents to perform various quality checks before submitting the data. The embedded programmes allow the verification of:

1- Consistency of the data between tables,
This step checks if the marginal totals reported in each table of the JHAQ are consistent across all tables. For example, for each function (HC), the total across all financing schemes (HF) in the HCxHF table has to be equal to the total across all providers (HP) in the HCxHP table, i.e. the values in the column “All HF” in the HCxHF table have to be equal to the values in the column “All HP” in the HCxHP table. Any detected differences are flagged up in the corresponding row or column in the relevant tables and all inconsistencies are listed in the “Report” worksheet by variable code together with the amount by which the respective variable differs between the two compared tables. A positive value indicates that the first listed table has a higher value for the same variable, and vice versa.

2- Consistency of the data within tables,
Any detected inconsistencies are listed by variable code together with an indication of which total is not equal to the sum of its subcomponents as well as the numerical difference. A positive figure indicates that the total is greater than the reported sub-components, and vice versa.

• The presence of negative values,

Entries in the tables cannot be negative as they refer to the consumption of goods and services.
If an individual data table is checked for internal consistency, the negative values check is performed for the relevant table and then any negative values are highlighted red and crossed out.

• The presence of atypical entries,

The atypical entries check provides information whether the data tables contain values in cells which are – if at all – only reported by very few countries and are thus atypical for health accounting.
If an individual data table is checked for internal consistency, the atypical entries check is performed for the relevant table. In the data tables, any cell containing an atypical entry will be highlighted for national data providers.
Should any atypical entries be identified, compilers should scrutinize in detail the transactions that led to entries in those cells and assess whether the accounting rules of SHA have been correctly applied. If they come to the conclusion that the transactions are recorded in the correct categories of the ICHA classifications, then the corresponding atypical entries represent unique – and correctly accounted for – features of the country’s health system. In this case a short description of the nature of the transactions should be included in the accompanying Metadata file under “II.3. Atypical entries”.
If, on the other hand, compilers come to the conclusion that the transactions are not recorded correctly, then they need to make adjustments in the concerned tables. In case the transactions recorded in a cell do not belong to the boundaries of SHA (e.g. they refer to intermediate consumption) the value of the respective cell should be deleted (and all cells that are affected by this change adjusted accordingly). In case the transactions are misreported and another category of the ICHA classification is more appropriate, the value of the cell should be transferred to the correct cell of the table.

3- The growth rates against the previous year and the magnitude of revisions as compared to previously submitted data. Results are grouped into three different categories:

• Breaks in series (the current questionnaire shows no data for an item that is not null in the other file);
• Newly reported (the current questionnaire contains data for an item that is empty in the other file);
• Differences (all other types of differences).

The results of the several calculations are then aggregated.

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

 Several methods are normally used for estimations:

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

Influence of the season and the number of working days on the statistics on health care income and expenditure is not assessed.

No additional comments.