Central Statistics Office

Government Accounts - Compilation & Output

CSO Dublin, Ardee Road, Rathmines, Dublin 6, D06 FX52, Ireland

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.

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.

Data on SHA is available for the years 2011 to 2017.

Not applicable.

Several data sources are used :

-          Surveys/census: 4

-          Public administrative records: 4

-          Financial reports: 2

-          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.

For the compilation of the SHA in Ireland the main provider of data is the Health Service Executive (HSE). HSE submits their data which has been coded using the SHA 2011 classification at T+18 months. The main private health insurance companies complete a survey template which they receive in August every year, the survey template is coded to the SHA 2011 classification and returned to the CSO the following October.  The main administration data sources are revenue data which are analysed and are mainly used for the compilation of out-of-pocket expenditure. Other data sources which are collected are non-HSE government expenditure - some of the other departments are contacted by email for health expenditure data (such as Department of Health, Prison Services, Department of Defence, Department of Education, Department of Social Protection, Department  of  Justice and the Gardaí). Data from Annual reports is also extracted as it becomes available - this would mainly relate to private healthcare providers and non-profit organisations.

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)

Internal data validation: data returned through surveys and collection are validated internally.

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.

None.

In fulfilling its mandate the CSO applies the best statistical standards and methodology, and adheres to the highest professional standards of impartiality, integrity and independence. The Office fully subscribes to the UN Fundamental Principles of Official Statistics.

The CSO operates under a strict legal regime, supported by a robust quality framework, the backbone of which is the European Statistics Code of Practice (ESCOP). This Code of Practice is made up of 16 principles covering the institutional environment, the statistical production process and the output of statistics. The Central Statistics Office (CSO) as a member of the European Statistical system is duty-bound and committed to following the Code. Each of the 16 principles has a number of specific indicator measures which are enacted through the policies, standards and practices of the CSO.

In accordance with the ESCOP quality standards, the quality requirements of CSO’s statistical outputs are:

• to be relevant with regard to meeting users information needs
• to be accurate so that estimates or indicators accurately and reliably portray reality
• to be timely so that statistics are made available to users in a timely and punctual manner
• to be accessible so that statistics are presented to users in a clear, understandable form, released in a suitable and convenient manner, available and accessible on an impartial basis with supporting metadata
• to be comparable and coherent to enable comparison internally, over time or among related sources.

The Quality Policy for the Office is set out in “Standards and Guidelines, Volume 1 (Quality in Statistics)”. This provides information and recommendations on best practice and contains clear guidelines and standards to ensure that the quality of CSO's processes and outputs are of the highest standard.

The CSO’s commitment to the quality of the statistics produced and disseminated is set out in its quality statement (https://www.cso.ie/en/media/csoie/aboutus/documents/csoqualitystatement.pdf). This is further supported by the Government of Ireland adopted “Commitment on Confidence in Statistics” which declares support for the existing laws and for those policies and practices instigated by the Central Statistics Office (CSO) to meet its obligations under the European Statistics Code of Practice.

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.

Expenditure included under SHA reporting should relate to Final Consumption Expenditure only, the expenditure includes some items that should not be included such as interest payments. This deviation is not material.

Data Users:

- Department of Health

- Department of Public Expenditure and Reform

- Researchers looking at health expenditure and forecasting future health spending.

Data users also use the Eurostat database for international comparisons.

Data is used in the compilation of ESSPROS.

Unmet user needs relate to timeliness of publication of data - users request more recent data. Users also request more detalied breakdowns of the data than what is published.

There are trilateral meetings held between the Central Statistics Office, Department of Health and Health Service Executive (main government healthcare provider) where the data compilation and the tables can be discussed. Any ad-hoc queries from other users or requests for information on the SHA are answered in as much detail as can be provided.

HF.1.1 - Missing data.  There may be a very small amount of government funding of healthcare not captured. We have not contacted all government departments amd are missing a few small public health care providers.

HF.2.1 - Voluntary Health Insurance Schemes. Missing data - Health care funded by holiday insurance has not been included.

HF.2.2 - NPISH Financing Scheme: Missing data. There are many non-profit providers of health care in Ireland, particularly in the area of providing care for those with a disability. The HSE is a major funder of this sector and this expenditure is captured in the HSE (HF.1.1) data. The accounts of some of the larger non-profit providers have been analysed and their non-HSE funded element of their expenditure has been included. However there are many providers where the non-HSE element of expenditure has not been included. There is a non-profit database that will be used in the coming years to improve the coverage of this area.

HF.2.3 - HF.2.3 includes some estimates of HF.2.2 as the latter is still in development and has been combined with HF.2.3.

HF.3 - missing data - Imported health care services funded by OOP are not captured.

HC.1.4 Missing (category reported elsewhere) - Home visits by GPs are not identified separately from HC.1.3 + HC.1.4.

HC.3.4 - Some providers in this category provide a wide range of services but have been coded to this category due to the predominance of their actitivity. For example, they provide out-patient services and residential care - some residential care provided by these categories are recorded as outpatient care.

HC.5 - For data confidentiality reasons some health insurance funded expenditure coded under HC.5 was recoded to HC.0.

HC.6 - Some of the data provided was only coded to first digit level, we have not been able to put this expenditure into a second digit level - instead we have put all the HC.6 data to one digit level.

At first digit level there is 100% completeness.

The SHA tables are the result of a number of different processes and estimation techniques.

The HSE provides most of the data on government spending and a large amount of work was undertaken to code all expenditure items accurately so it can be assumed that this data is very accurate. 

The larger private health insurers are surveyed annually for the data on private health insurance expenditure, this data is also assumed to be accurate.

The out-of-pocket expenditure uses a number of techniques in order to arrive at an estimate. Very often the OOP expenditure is triangulated on a number of different sources such as revenue data, household budget survey and price quantity techniques. Using a number of different techniques does allow for validation of the estimates. There are some areas of out-of-pocket expenditure that need further improvement in the estimates. 

CSO only use a survey for the private health insurers and it surveys all of the largest health insurance providers.

Not applicable.

There are some items included that should not be included in final consumption expenditure e.g. interest payments - the deviation is not material.

Non-Profit Providers: There is ongoing work to improve the coverage of data on expenditure on health care.  In particular, further development work on non-profit providers of health care and their non-government funding is ongoing.  The funding of health care services from non-profit institutions serving households financing schemes (HF.2.2) is under-represented in the current data and will be revised in future data reporting.

Residents and Non-Residents:  Health expenditure should relate only to residents of the Republic of Ireland.  Most data sources do not capture information on residence and thus expenditure on non-residents may be included in the data (export of health care services).  Expenditure by residents in other countries is also difficult to capture, particularly out-of-pocket expenditure.  Some expenditure funded by the HSE and private health insurers has been captured.  There is likely to be an underestimate of import (purchasing of healthcare abroad) of health care services in the Irish SHA data. Data sources do not allow for the exclusion of medical costs for non-residents in general. A small amount of expenditure related to E111 and E112 expenditure has been excluded from HSE (HF.1.1) expenditure. Medical costs for residents abroad that are funded from out-of-pocket expenditure (HF.3) have not been captured.

Health Care/Social Care Boundary: The project to implement the SHA reporting standard in Ireland reviewed the boundary of health care and social care with the HSE Service Providers.  This resulted in a number of services and the associated expenditure, previously categorised as social care, being reclassified to health care.  Given that health care and social care are often delivered in the same package of services, it has been hard to separate the two types of services and thus the predominant activity (generally health care) has been used to classify the activity and associated expenditure.  This has resulted in the amount of health care expenditure been somewhat over-stated in some areas.

Not applicable.

Not applicable.

No information available.

Not applicable.

Not applicable.

Not applicable.

No information available.

None.

Not applicable.

Not applicable.

Data will normally be revised for the previous year only, unless there has been a change in statistical processing or coding.

Data has been revised for all years 2011-2016. The revisions to the years 2013-2015 are small for the most part. There is a large revision to Out-of-pocket payments (HF.3) on nursing home care (HP.2.1), this has decreased in 2013-2015 due to a review of the methodology used. Previously dental care has been classified to HC.1.3+HC.2.3 only,  now it is possible to split dental care into curative and preventative care so it is also now classifield to HC.6. This split has been done for all years 2011-2016.

For the reference period 2014-216, there were no revisions for the returns for 2014/2015. There were revisions for all years with the 2016 return.

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.

Ireland does not publish first results.

Final national data is published on the CSO website after T+18 months.

Ireland has transmitted the SHA data within the legal timeframe.

CSO complies with the Comission Regulation 359/2015 transmission deadlines.

Not applicable at national level.

Not applicable.

Breaks in time series resulting from methodological changes

Data is coherent with ESSPROS and is used for the ESSPROS accounts, the SHA data is taken annually to update the ESSPROS data.

Not applicable.

Coherence in accounting principles exist and there is coherence to the extent that the Household Budget Survey would form a basis for the estimation of some of the expenditure items in both National Accounts and SHA. However there are differences in the health classifications within SHA and National Accounts and as such it is difficult to be exact with the coherence.

SHA includes government payments for schemes such as GP care and Pharmaceuticals in government expenditure. Included in  National Accounts as personal consumption are a number of goods and services, which are paid for by the state.  These form part of state transfer payments.  For national accounts purposes it is considered that the state provides the money to the households and the household pays the concern providing the good or service. They thus form part of personal income and personal expenditure.  Principal among these are medical services supplied by GP’s to households and medical goods supplied to households by pharmacists. Some veterinary goods and services are also included in the National Accounts estimates, while SHA gives the expenditure for human health.

Within SHA the government health expenditure is larger than COFOG 7.

Atypical entries:

The SHA is available on the CSO website.

https://www.cso.ie/en/statistics/governmentaccounts/systemofhealthaccounts/

In June of each year the SHA data is published in the form of an electronic release. To announce the release there would be twitter and social media updates.

The SHA data is published annually on the CSO website in the form of an electronic release.

https://www.cso.ie/en/statistics/governmentaccounts/systemofhealthaccounts/

The SHA data is included in ad-hoc publications such as the Statistical Yearbook of Ireland.

https://www.cso.ie/en/csolatestnews/presspages/2018/statisticalyearbookofireland2018/

THe SHA data is available in the CSO database STATBANK. The tables published in the annual Electronic Release are available in Statbank. This includes tables on the main aggregates as well as the three cross tabulations. There is also a table reconciling the data.

https://www.cso.ie/px/pxeirestat/Database/eirestat/System%20of%20Health%20Accounts/System%20of%20Health%20Accounts_statbank.asp?SP=System%20of%20Health%20Accounts&Planguage=0

System of Health Accounts - 1,671 hits

System of Health Accounts 2016 release - 2,067 hits.

Not applicable.

Used in the Measuring Irelands Progress Publication

https://www.cso.ie/en/releasesandpublications/ep/p-mip/mip2016/hh/

Statistical Yearbook of Ireland

https://www.cso.ie/en/statistics/statisticalyearbookofireland/

The metadata for SHA tables has recently been published on the CSO website.

https://www.cso.ie/en/methods/governmentaccounts/systemofhealthaccounts/

There are some background notes accompanying the annual electronic release. 

Background information on the  following is provided on the CSO website.

Private health insurers survey:

https://www.cso.ie/en/methods/governmentaccounts/expenditureandestimatesofprivatehealthinsurers/

Private Hospital Survey:

https://www.cso.ie/en/methods/governmentaccounts/incomeofprivatehospitals/

All information on quality standards within the CSO is available here:

https://www.cso.ie/en/methods/quality/

A quality report for System of Health Accounts in Ireland is not yet published.

Metadata provided on all elements.

Metadata has only been recently available on the CSO website, so this information is not available.

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

In Ireland the data used within the SHA is treated as strictly confidential in accordance with Section 33 of the Statistics Act.

Disclosure of information on HP.5 * HF.2 is suppressed to ensure confidentiallity.

The data collected in Ireland for the System of Health Accounts provides an accurate picture of health expenditure. A large project was undertaken to setup the System of Health accounts, this includes ensuring data on government expenditure through the HSE is accurately coded. Similarly the survey of private health insurance companies ensures accurate coding of their data to the SHA standard. https://www.cso.ie/en/methods/governmentaccounts/expenditureandestimatesofprivatehealthinsurers/

The Out-of-Pocket expenditure relies on estimation techniques that draw on other surveys such as Household Budget Survey, Census data and administration data sources such as revenue data and medical card data and also annual report data. Using these methods ensure CSO can estimate out-of-pocket expenditure a number of different ways which allows for verification of methods.