Croatian Institute of Public Health

Public Health Service, Department for Health Economics

Rockfellerova 7

HR-10000 Zagreb

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.

Croatian Institute of Public Health (CIPH) is compiling SHA data on the basis of the Official Statitics Act, Programme of Statitical Activities and Annual Implementation Plan of Statistical Activities of the Republic of Croatia.

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).

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.

2013-2016.

Not applicable.

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

-          Surveys/census: 1

-          Public administrative records: 9

-          Financial reports: 3

-          Other: 1

Surveys/censuses

Public administrative records

Financial reports

Other

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.

Majority of the data from social insurance fund is transmitted in standardised electronic form containing data compiled according to mapping of different internal social insurance fund's code books into SHA categories which is prepared and provided by Croatian Institute of Public Health. The remaining data from social insurance fund are transmitted in non-standardised form and procesed and SHA coded by Croatian Institute of Public Health. The data from other reporting units (financing agents) which use public administrative records are transmitted in standardised electronic form, while data from survey and financial reports are processed and SHA coded by Croatian Institute of Public Health.

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)

Croatian Institute of Public Health also provides national data validation - manual validation is performed throughout the compilation process:

- evaluation of completeness and coverage of each data source

- control and analysis of microdata received from each reporting unit

- analysis of time series for each data source

- cross checking between SHA data and other published data and reports on health care expenditures.

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.

Not applicable.

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.

The majority of SHA data for Croatia are collected using "bottom-up" approach - individual data from administrative data sources are collected and compiled according to SHA methodology. The main source of data where this approach is not applied is Household Budget Survey which is source of majority of data for HF.3. As Household Budget Survey is executed in Croatia only every third year (2011, 2014, 2017), data for 2015 and 2016 had to be estimated from data for 2014. Besides that, questions in Household Budget Survey are not adapted to SHA methodology, so estimations are needed to obtain data according to SHA methodology. Due to all mentioned reasons, SHA data on HF.3 derived from Household Budget Survey are considered to be of lower quality and less reliable compared to the remaining SHA data.

Data users at the national level are Ministry of Health as well as researchers and analysts in the area of health care.

Croatian Institute of Public Health has regular contacts with Ministry of Health which has opportunity to give its opinion from the user point of view.

The breakdown of HF.3 into HF.3.1 ("Out-of-pocket excluding cost-sharing") and HF.3.2 ("Cost-sharing with third-party payers") is not available.

Not available.

The overall accuracy of SHA data depends on the accuracy of the data used to compile them. In general, data derived from administrative data sources are more accurate, while the data from Household Budget Survey and financial reports which undergo significant tranformations before inclusion into SHA data, are less accurate.

Household Budget Survey is used as the main source of data for HF.3 expenditures. Sampling error indicators for data categories from Household Budget Survey (according to their COICOP codes) which are used for SHA data compilation, are presented in the following table:

Not available.

Not available.

We are not aware of any double-counting of expenditure items in SHA data. However, we are countinouosly checking our data for possible double-counting and in any such case we do revision of complete time series of the data (we had such case last year when we discovered that certain expenditure reported by social insurance fund as final consumption was actually internal transfer from voluntary to mandatory health insurance section within the social insurance fund - we immediately asked for corrected data and did revision of the complete time series of SHA data).

Health care goods and services by non-residents are excluded .

We are not able to report the underground/informal/illegal health care goods and services (Croatian Bureau of Statistics who operates Household Budget Survey in Croatia provided us with information that informal payments are not included in data collected as part of this survey which is our main source for HF.3).

None.

Not available.

Not available.

Not available.

Stated in metadata according to HF categories.

Not available.

Not available.

Not available.

Not available.

Not applicable.

SHA data undergo revision whenever new or corrected data on certain health care expenditure become available for a certain year. One of the main problems with SHA data is still the fact that health care providers owned by the state (mostly hospitals) accumulate losses which get covered only several years after they were generated and which can not be so precisely devided into HC categories as it is possible for expenditures which actually get paid (therefore estimations are needed). 

Revised data for 2013, 2014, 2015 and 2016 are included in submission in 2018. There has been intensive correspondence with Croatian Health Insurance Fund (providing HF.1.2.1 and big part of HF.2.1) concerning problems with huge variations in HC.5.1.1 among different years (mentioned in point 8. of your validation) without knowing the reasons. This resulted in series of meetings and intensive mail correspondence during which several methodological problems have been discovered (limited not only to HC.5.1.1) in reporting of SHA data from Croatian Health Insurance Fund, therefore revised data for entire period 2013-2016 has been requested. The revisions included significant changes in HC.5.1.1, HC.1.3.1, HC.1.3.2, HC.1.4, HC.3.4, HC.5.1.3 and HC.6. 

Additional revision of data for 2013-2016 included in submission in 2019: Source for expenditures in HF.3 HC.5.1.1. and HF. 3 HC.5.1.2 was changed - instead of Household Budget Survey data we decided to use data from the report on drug utilisation in Croatia prepared by Agency for Medicinal Products and Medical Devices of Croatia as their data are more accurate.

Not available.

Croatia transmits its data to Eurostat in compliance with the Commission Regulation 359/2015 transmission deadlines.
Data and reference metadata for the reference year T are transmitted to Eurostat by 30 April T+2.

Provisional results are published in May T+2.

Final results are published in October/November T+2 (after completion of Eurostat validation). Revised results are published after each revision of the data.

Croatia complies with Commission Regulation 359/2015 transmission deadlines.

Croatia delivers the data for T-2 to Eurostat by 30th March T.

Not applicable at national level.

Not applicable.

Breaks in time series resulting from methodological changes

2013-2017 for SHA 2011 data.

SHA and ESSPROS data (managed by Croatian Bureau of Statistics) are regularly compared (although they are compiled by different institutions using different methodologies) and checked for any differences which can not be explained by differences in SHA and ESSPROS methodology.

Not applicable.

Does not exist for the time being.

Atypical entries:

Preliminary SHA data for T-2 are regularly published in May each year on internet site of Croatian Institute of Public Health.

SHA data for Croatia are regularly published in Croatian Health Statistics Yearbook (yearbook for 2017 available on the link: https://www.hzjz.hr/wp-content/uploads/2019/03/Ljetopis_2017.pdf (SHA data published in the statistical yearbook are NOT replaced after revisions).

SHA data for Croatia are also regularly published in annual SHA reports (last available is report for 2016 available on the link: https://www.hzjz.hr/wp-content/uploads/2013/11/Bilten_SHA_2016_v_2_sije_2019.pdf ). Whenever there is a revision of SHA data for certain year, new SHA report with SHA data for that year is prepared and published (with "revised data" label).

Not available.

Not available.

Not applicable.

Not available.

Methodology is described in a special paragraph on methodology in the annual SHA report.

There are no official documents concerning quality management of SHA data.

Not available.

Not available.

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

The Official Statistics Act which regulates production and dissemination of SHA data in Croatia also obliges Croatian Institute of Public Health to keep data collected from reporting units confidential and to publish only aggregated SHA data.

Collected data are kept confidential as required by regulations and only aggregated data are published.

No further comments.