National Institute for Health Development

Health statistics department

Hiiu 42, 11619 Tallinn, Estonia

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

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

Accounting period: Health expenditure and financing data pertain to the calendar year (1 January to 31 December).
The time coverage of this Quality report is 2014 to 2016 reference years.

National Institute for Health Development (NIHD) is compiling SHA data in accordance with its statutes and at the request of the Ministry of Social Affairs. Data is published on webpage www.tai.ee, in Health Statistics and Health Research Database http://pxweb.tai.ee/PXWeb2015/index.html .

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.

Commission Regulation 2015/359 concerns the collection of data on "current expenditure on healthcare" which is defined as the "final consumption expenditure of resident units on health care goods and services".
There is a very close relationship between the concept of "final consumption expenditure" as defined in the System of Health Accounts (SHA) and in National Account and, as a consequence, also between the underlying economic transactions as recorded in the two accounting frameworks.
In National Accounts there are two types of statistical units: institutional units and local kind-of-activity units (KAU). A local KAU groups all the parts of an institutional unit in its capacity as producer which are located in a single site. A local KAU belongs to one and only one institutional unit.
SHA uses the same two types of units for data compilation.
Local KAUs operating as providers of healthcare goods and services to resident units are statistical units in SHA.
Also transactions by institutional units are recorded in SHA, in which framework institutional units are also referred to as "financing agents". More precisely, SHA financing agents are institutional units that manage one or more financing schemes. The transactions are executed by the financing agents, according to the rules of the financing schemes.
Financing agents serve as key statistical units in producing national health accounts. While financing schemes are the key units for analysing how the consumption of health care goods and services is financed, the data concerning the relevant transactions are collected either from the financing agents that operate the different financing schemes or from the providers.
The concept of "healthcare financing schemes" in SHA is an application and extension of the concept of "social protection schemes" defined by the European System of Social PROtection Statistics (ESSPROS):  "a distinct body of rules, supported by one or more institutional units, governing the provision of social protection benefits and their financing ...". The social protection scheme is the statistical unit in ESSPROS. It is an analytical unit that allows describing the complete structure of the social protection financing system:  expenditure and receipts.
According to SHA Manual 2011, "the key concepts for describing the structure of the health care financing system are based on measuring: (a) the expenditure of health care financing schemes, under which goods and services are purchased directly from health care providers, on the one hand, and (b) the types of revenues of health care financing schemes, on the other hand.  
Commission Regulation 2015/359 limits its scope to the collection of data on the expenditure of health care financing schemes.

SHA focuses on the consumption of health care goods and services by the resident population irrespective of where this takes place. This implies the inclusion of imports (from non-resident providers) and the exclusion of exports (health care goods and services provided to non-residents).

Expenses of non-residents are excluded as much as possible.

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.

2003-2017

Not applicable.

Several data sources are used (as of data notification in March 2018):

-          Surveys/census: 4

-          Public administrative records: 7

-          Financial reports: 3

-          Other: 0

Surveys/censuses

Public administrative records

Financial reports

Annual.

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

Data for Estonia is collected by National Institute for Health Development in in SHA-standardised form for ministries, standardised form from healthcare providers, non-standardised form from other institutions and is processed and SHA-coded by National Institute for Health Development. Data request is sent official letter signed by the Director of Institute to data providers annually. Double counting is eliminated from the calculations during the processing

The data are verified and if necessary, specified together with the data providers and all made expenses are classified according to the function (purpose) for which the money was spent. 

During the work, it will be specified as much as possible through which service provider money was spent for the corresponding purpose, and where final consumption took place. Since the objective is to classify expenditure according to final consumption (and exclude intermediate consumption), then the contributor is often not the one, which carries out the corresponding activity or where the money is actually spent – therefore, the data obtained through organisers will be further classified according to the corresponding service providers and activities. In practice, classification means marking each amount spent according to all applicable classifications (financing source, health function, service provider, and financing scheme). Expenditure where the primary proposes of the activity is not health or related to health and health care indirectly will be excluded. Therefore, the labour and social field expenditure of the Ministry of Social Affairs is not included. Neither does health expenditure include compensations for the temporary incapacity to work paid by the EHIF.

The 2018 JHAQ includes a number of features which allow national data correspondents to perform various quality checks before submitting the data. The embedded programmes allow the verification of:

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

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

• The presence of negative values,

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

• The presence of atypical entries,

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

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

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

Results are compared with initial data and calculations of previous years in Estonia. General available information is cross-checked between data sources: National Accounts data from Statistics Estonia, pharmaceutical market data from State Agency of Medicines, household expenses from Statistics Estonia Household Budget Survey, annual reports of the Commercial (Business) Register of health service providers. 

SHA data is compiled both by a bottom-up approach as well as by a top-down approach, depending on the data source. Compilation is done by financing schemes and by different health care functions/task areas. 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.

For households out-of-pocket payments is used the volume of sales of the providers and retail sales (glasses), also data from Health Insurance Fund and Ministry of Social Affairs about household co-payments for medicines and aids. Volumes of sales of services are allocated to functions by means of distribution keys. Data for over-the-counter medicines expenses comes from the State Agency of Medicines.

Some adjustments have been done in data if some expenses were classified differently in a single year when compared to neighboring years in historical data. This has been related to recalculations of time-series according to the SHA 2011.

Voluntary part in EHIF health insurance system has been distributed by HF proportionally. 

Authorities responsible for SHA data collection are working to ensure that the statistical practices used to compile national health accounts are in compliance with SHA methodological requirements and that good practices in the field are being followed, according to the methodology underlined in the SHA 2011 Manual and European Statistics Code of Practice respecting professional independence of the statistical authorities. Procedures are in place to plan and monitor the quality of the health care expenditure statistical production process.

National Institute for Health Development operates as a central institution in charge of health statistics in Estonia. The Department of Health Statistics does data collection, analyses and publishing of health expenditure statistics in accordance with internationally approved SHA methodology. The statistical information is produced by following the principles of objectivity, reliability, relevance, confidentiality and transparency. Legal acts: https://www.tai.ee/en/r-and-d/health-statistics/legal-acts

Dissemination principles: http://pxweb.tai.ee/esf/pxweb2008/dialog/Info/HealthStatisticsDisseminationPrinciples.pdf

Overall quality is good. Bases on administrative data, which is complemented by special requests for function and provider details. Primary data are cross-checked with publicly available general economic data. 

Main users of SHA data in Estonia are Ministry of Social Affairs, professional health associations, health professionals, media, researchers, students. Key indicators that are often requested are health expenditure in general, public and private expenditure with services distribution, the share of health expenditure in GDP.

Based on 2016 health statistics users satisfactory survey (NIHD) were satisfied with health expenditure data publishing deadline 88% of respondents, with reliability 90% and with level of detail 78%.

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

Household out-of-pocket payment HF3 is without distribution between HF31 Out-of-pocket excluding cost-sharing and HF32 Cost-sharing with third-party payers. From services over-the-counter medicines HC512 are without any cost sharing. Rest of the services include some cost sharing (HF321), but from household expenditure paid services without cost-sharing and services with cost-sharing are not distinguished.

Review of LTC health and social expenditure data is in progress, based on 2017 pilot data collection current LTC health expenditure is underestimated. Rate will be specified next year. 

Ministry of Social Affairs started mapping of social welfare services in 2019 according to the 2018 OECD guidelines about Accounting and mapping of long-term expenditure under SHA 2011.

The quality depends on the quality of administrative and reported data.

Out-of-pocket expenditure distribution between services is estimated.

No sampling surveys are used, except health spendings of private companies (EKOMAR module E, Statistics Estonia).

Sample surveys are not used, only for health spendings of private companies.

No sample surveys, except health spendings of private companies.

Not relevant.

Health care goods and services used by non-residents are excluded, except in case of out-pocket expenses paid directly to service provider. 

For health spendings of private companies is used module E in EKOMAR survey 2008, 2013, provided by Statistics Estonia.

Not applicable

Not applicable

Not applicable

Certain minor non response has been compensated with previous year data (eye-glasses stores sales).

Not applicable

Not applicable

Errors due to misinterpretation in coding are possible if description of expenses is not complete.

Not applicable.

Not applicable.

Not applicable.

Generally, revisions are made only if new relevant information emerge or mistakes have been discovered. New health expenditure data are published T+10 months annually.

Main reason for revison of previously delivered data during the 2015-2018 data delivery was the implementation of SHA2011 and introduction of the new methodology for estimation household expediture.

Main reason for the revisions during the 2015-2019 data delivery has been the implementation of SHA2011 and the introduction of a new methodology for estimation household expenditure. Revision of the time series during the last years does not correspond to the general revision policy. It has been an exceptional period, involving a lot of extra-work, including reconsiderations and reclassifications of previous data according to the new principles, also knowledge with exploration of new available information. 

For example, in 2018 with new 2016 data also revised data series were submitted for years 2008-2015. There were two causes for revision. Correction inlcuded change in FS table where revenues for Russian military pensioners were removed from FS2 to FS71. In main tables including HF distribution according to the discussions results with WHO and OECD voluntary health insurance expenditure in Estonian Health Insurance Fund (payments of private persons to EHIF for purchasing EHIF health insurance) has been removed from HF121 to voluntary health insurance schemes HF21.

Time-series are harmonised step by step.

Household spending increased by 7% on average over the 11 years concerned within the change in methodology and taking into use of administrative sources instead of household budget survey data from 2013. Biggest impact in addition to the elimination of annual unspecified fluctuations was the elimination of under-coverage of OOP spending for years 2010-2012 (average increase 22,7%).

The total number has been affected by an average of 1.2%.

Member States are required to transmit their data to Eurostat in compliance with the Commission Regulation 359/2015 transmission deadlines.
Data and reference metadata for the reference year T should be transmitted to Eurostat by 30 April T+2.

National data are published in Estonian Health Statistics and Health Research Database annually by 31 October T+1.

Estonia does not publish first results. For international comparison we calculate preliminary data by HF in the beginning of April T+1.

Results are generally final after 12 months from first results.

There were no deviations from deadlines in the reference period.

As planned.

Not applicable at national level.

Not applicable.

Breaks in time series resulting from methodological changes

Generally comparable time series for 15 years. Same OOP spending (HF.3) calculation methodology is implemented in the SHA 2011 recalculated time-series for 2003-2017. During this time-period some changes have influence for comparability listed here.

Data according to SHA 2011 is available for years from 2003 to 2017.

Calculations are cross-checked with other sources at national level.

Not applicable.

Results are compared with the National Accounts.

Atypical entries:

Coherence is verified within the validation process (see point 3.4).

At the national level annual news release is published with national data at the end of October T+1 on the National Institute of Health Development webpage (www.tai.ee). 

Estonian Health Care Expenditure in 2015 (last in English)

https://www.tai.ee/en/health-data/research-reports/download/412

2016 and 2017 analysis in Estonian only  https://www.tai.ee/et/terviseandmed/uuringud/download/435  https://www.tai.ee/et/terviseandmed/uuringud/download/475

Health in the Baltic countries 2016

https://www.tai.ee/en/health-data/research-reports/download/447

The online national Health statistics and health research database is available on the National Institute of Health Development webpage: http://pxweb.tai.ee/PXWeb2015/index_en.html

Data online publication includes metadata.

Not available.

Not applicable.

Used by Ministry of Social Affairs.

The metadata are enclosed to the tables and explained in published analysis.

Methodology change in detail is described in the analysis:

Health expenditure in Estonia 2013. Change in Methodology

https://www.tai.ee/en/health-data/research-reports/download/339

Health expenditure 2014. Change in OOP expenditure calculation methodology

https://www.tai.ee/en/health-data/research-reports/download/366

Classifications are published under Health statistics metadata section (in Estonian)

https://www.tai.ee/et/tegevused/tervisestatistika/metaandmed/klassifikaatorid

Links are added to SHA 2011 revised version in Estonian and in English webpage.

Quality report published for 2012.

Metadata is provided in publications and in public database.

Not available.

Mainly secondary use of administrative data.

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

Statistical confidentiality is applied, aggregated data is published.

Data delivery 2018 JHAQ include files for years 2008-2016, and preliminary aggregates for 2017. 2008-2015 corrections in 2 main tables including HF and FS table have been made. Details of these corrections are provided at page V. Revisions. NB As previously provided HKxHP tables for 2012-2015 are not updated, only 2016 data file include new HKxHP filled in table in current data delivery and for previous years HK tables are left empty. For the HCR.1 Long-term care (social) first estimates have been calculated in 2018. As the 3.04 data transmission (2008-2017) was perfomed without filling in HCR.1 in the tables, data is added in separate file. for your information. If during the validation process any updates for data-files are needed, HCR.1 will be added to the JQ files. These first estimates will be specified later this year within 2017 HE data collection process, when Ministry of Social Affairs will review LTC data according to the new Guidelines for Accounting Long-Term Care Expenditure under SHA 2011. Results will be provided within next year data delivery.