Centraal Bureau voor de Statistiek (Statistics Netherlands)

Team Health and Care

P.O. Box 24500

2490 HA The Hague

The Netherlands

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

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. (i.e. financing by rest of the world of healthcare use by residents)

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

4. Parts of NACE rev.2:

• 4711 - with regard to sale of over the counter pharmaceuticals.
• 4773 - pharmacies.
• 4774 - Retail sale of medical and orthopaedic goods in specialised stores (includes also sale of OTC pharmaceuticals).
• 4932 - Taxi operation, with regard to patient transportation.
• 6512 - Non-life insurance, with regard to health insurers for private supplementary health insurance, and operation of compulsory health insurance.
• 8412 - Regulation of the activities of providing health care, education, cultural services and other social services, excluding social security, with regard to the ministry of public health, welfare and sports.
• 8422 - Defence activities, with regard to health care for defence personnel.
• 8423 - Justice and judicial activities, with regard to health care provided by the Justice department, e.g. prison hospital.

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.

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).

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.

1998-2022.

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: 1998-2022.

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.

Disclosure of data on specific healthcare providers is suppressed by including them in a larger group of health care providers.

Provisional figures for year t-1, revised provisional figures for year t-2 and definite figures for year t-3 are published in the Netherlands in the second quarter of year t.  

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.

In May/June of each year CBS publishes a news release on care expenditure of the previous year; it includes also the SHA indicator current expenditure as percentage of GDP.

News release in 2023: Care expenditure up by 1.2 percent in 2022 | CBS.

Data are published as open data and are accessible using the CBS Statline app.

The three core tables:

• Opendata CBS (1).
• Opendata CBS (2).
• Opendata CBS (3).

Tables showing the link between national and international figures:

• Opendata CBS dataset (1).
• Opendata CBS (2).

Revenues of financing schemes:

• Opendata CBS table.

On the site in Dutch, more options are available et this webite.

The Data Portal provides the opportunity to use scripts for downloading tables:

• CBS Open data StatLine.

Not applicable.

None.

The metadata are enclosed in the tables. General descriptions of the method: Health expenditure ; CBS Zorguitgaven on the revision of 2015.

Quality reports are based on self-assessment for the process.

In the past 12 months no corrections have been made on published results.

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.

Checks are carried out for completeness, internal and external consistency and plausibility of the collected internal and external data. Where necessary, corrections are applied.

The sequential comparability of provisional data and final data shows that usually the difference is small for the aggregates (less than 1 %) and bigger for data that are disaggregated.

The comparability with SNA aggregates shows that after correcting for differences in definitions and scope, the data are reasonably good reconcilable, see e.g.

Health expenditure data for policy: Health accounts, national accounts or both? (Health pol.2018).

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

Main users :

• RIVM (Institute for Public Health and the Environment); usage for Cost-of-illness studies. RIVM receives detailed tables per year that are further processed with data on population and illnesses; including breakdown according to the budget of the Ministry of Health.
• CPB (Netherlands Bureau for Economic Policy Analysis; usage for their medium-term forecasts.
• Ministry of Health and Welfare; usage for main indicators; CBS produces linkages tables from Care accounts to the Health budget.
• General public, including media like newspapers, magazines, independent journalists.

CBS has regularly meetings with the Ministry of health and welfare, and RIVM. With CPB we have a meeting once every two years, and several contacts during the year. Several tailor made answers to questions have been produced.

Data are complete as far as the Commission regulation is applicable.

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.

As the SHA tables are the result of an integration process, as well as of estimation of details within the SHA framework, the character of the figures is inevitably not 100% accurate. The final figures derived from the Digimv source cover around 60 per cent of all expenditure, and are a solid source (missing less than 1% of annual reports). The integration process itself ensures a better accuracy, as we compare at least two sources whenever possible: Digimv and the sources on financing. Direct out of pocket expenditure is based on estimates, of which around 50% is a direct estimate and 50% a residual, with some minor expenditure figures based on an initial estimate and development. Some of the data on providers are also based on estimates like TCAM providers.

Not applicable.

See also coherence and comparability in this case of integrative statistics.

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.

Data submitted in compliance with the legal deadline described in section 14.1.

Not applicable at national level.

The figures of the Health Accounts are comparable sequentially, due to the fact that the used definitions and concepts are univocal and guide the process of integration. The sequential comparability applies both to levels and changes. However, if a choice has to be made between them, the level is preferable for data in current prices.

Breaks in time series resulting from methodological changes

The SHA figures can be reconciled with figures from Business statistics (as they are an important source for the care accounts of which the SHA figures are a subset); with ESSPROS as far as ESSPROS covers the SHA figures or the figures of the care accounts.

Atypical entries

The statistics are secondary, the burden on data providers or respondents is the one from the sources. Additional: specific tables from Zorginstituut Nederland, that serve also National accounts and Government finance departments of CBS.

The system of health and social care accounts will be revised once every five to ten years. All actors are checked in terms of completeness, validity and reliability. New actors are created if necessary; actors can also be merged. We apply all new insights, methods and sources. The results of the last big scale revision will be published in 2024-2025.

In 2022-2024 team Health and Care has revised and is (May-August 2024) revising the whole system of Health and Social care Accounts. Some major sources have become available: microdata on invoices by healthcare providers, from health insurance companies for the compulsory health insurance and for the long-term care insurance; micro- and macrodata from the FRIBS (Framework Regulation Integrating Business Statistics) statistics for the section on human health and social work activities. This has led to more detailed allocations of expenditure to SHA functions. Publication is foreseen in the last quarter of 2024. The metadata file will be updated accordingly.

In 2016-2018 team Health and Care has revised the whole system of Care Accounts, partly aligning with the revision of National Accounts that was going on in the same period. Several estimates of providers have been re-assessed (e.g. hospitals (downward), TCAM (Traditional, Complementary and Alternative Medicine) providers (downward), pharmaceuticals providers (downward), GP's (general practitioners) (upward), Psychologists (upward), care for the handicapped (upward)). Overall, the revision has been downward in total. New data sources have been used for this, as well as for other providers and for structural information. For instance, the income statements of the large institutions have now a better breakdown according to type of (health) care service and from 2015 onwards, also a breakdown according to financing scheme. This has led to significant changes in the structure of financing and the structure of products, and for SHA, the structure of functions.

The total amount of deductibles in the compulsory health insurance is now almost fully based on the information of health insurers instead of information of the ministry of health, the difference being that the former refers to actually paid cost-sharing, while the latter refers to the supposedly (nominal) paid cost-sharing (which is higher than the one actually paid as insurers have some choice to offer exemptions from cost sharing).
As far as curative care is concerned, there is a better estimation of the expenditure on hospitals (lower) vs. expenditure on independent treatment centres (daycare mostly) (higher); there is also a new estimation on the distribution between in-patient, daycare and outpatient treatment for hospitals (general, university, special) and for independent treatment centres. E.g. for university hospitals the first estimate was 49% share of inpatient treatment in 2015, it is now 44.2%. The estimates are based on an analysis of the expenditure on diagnosis treatment combinations.
The old figure of NIPSH financing schemes was related to much of double-counting, which has been removed as far as possible. However, part of the financing of e.g. hospitals comes out of NPISH, but the team does not know how much. This is an omission for which the team health had up till now no real good data. This is one of the many items that the team health and care still has for a new revision of the Care accounts.

Several data sources are used:

• Surveys/census: 1.
• Public administrative records: 1.
• Financial reports: 2.
• Other: 2.

Surveys/censuses

Public administrative records

Financial reports

Other

Several data sources are used:

• Surveys/census: 1.
• Public administrative records: 1.
• Financial reports: 2.
• Other: 2.

Surveys/censuses

Public administrative records

Financial reports

Other

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).

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

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.

Main sources

Statistics Netherlands: surveys of health and social care providers; National Accounts; price and tariff data.
External sources: financing data (National Health Care Institute, the former health insurance fund); budget data (Ministry of Health, Welfare and Sports); tariff information (Dutch Health Authority), Vektis (health care data of the health insurers), annual reports.

See also Health care institutions, Health care practices, Production statistics.

Structure of integration framework

The figures on health and social care and those on health care according to SHA use the system for integration of statistics: the health and social care accounts. The production of the figures according to the System of Health Accounts is integrated in the production process. Information is collected for groups of providers, called actors (e.g. physiotherapists, general hospitals, internal occupational health agencies); this is done for around 80 actors. For each actor (e.g. mental health care institutes) expenditure on specific types of care (e.g. psychiatric care) is allocated to financing schemes (e.g. private health insurance) and to the functions of the types of care (e.g. inpatient curative care). Each actor is mapped to a category of the Health Care Providers classification of the System of Health Accounts.

Provisional figures for the previous year, published in May or June, are based on external sources and supplementary estimates. Revised provisional and final figures are based on internal sources of Statistics Netherlands and some external sources.

None.