Office of Statistics Liechtenstein

Registers

Aeulestrasse 51

9490 Vaduz

Liechtenstein

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).

As Liechtenstein is very small (less than 40'000 inhabitants) the country itself offers only a limited health system. Some health activities suche as specialised hospitals are only available abroad. All in all around 60% of health services are provided within the country and 40% are provided by the nearby country (HP.9 Rest of the World).

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.

Due to the small size of the country (less than 40,000 inhabitants), Liechtenstein offers only a limited variety of health services. Around 40% of health services are imported from abroad, which means that the category HP.9 Rest of the world is rather important.

For Liechtenstein Health Accounts data is available since 2013.

Not applicable.

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

-          Surveys/census: 0

-          Public administrative records: 8

-          Financial reports: 2

-          Other: 1

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.

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)

Liechtenstein compiles its health accounts data by a bottom-up approach, meaning all expenses are collected and added up. Some expenses e.g. voluntary insurance is pro rated by the distribution of  health expenses covered by compulsory insurance. Some expenses are estimated on the basis of Swiss data. Almost no data is available on OOP costs, therefore these expenses are estimated on the per capita OOP-expenses in Switzerland. As both countries have very similar living conditions (e.g. health system and the living costs), this method provides a fairly good estimation.

No adjustments are made.

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.

As health accounts data is mostly put together from administrative data sources, the quality is good. The main weaknesses are the Out-of-pocket (OOP) expenses which have to be estimated on the basis of per capita OOP spending in Switzerland. With less than 40,000 inhabitants Liechtenstein is too small to collect lots of data with sample surveys, therefore no changes are planned in near future. Furthermore living conditions in Liechtenstein and Switzerland are very similar, so the estimation on basis of Swiss data is expected to be very reliable.

Health accounts data  is mainly used by the following parties: parliament, government, office of public health, local health care providers and researchers. There is an increasing interest in expenses for social long-term-care. The NSI will try to put together these expenses in the near future.

The Office of Statistics in Liechtenstein conducts a user survey every five years. The last one took place in 2018 (in German only):

https://www.llv.li/inhalt/118512/amtsstellen/nutzungsbefragung

In general, people are satisfied with the available information about public health. There are no known unmet user needs.

None.

Concerning Liechtenstein health accounts data, expenses for day care (curative, rehabilitative and long-term) are included in the according outpatient category.

Also, there is no information about HF.2.3 Entreprise financing schemes and HF.4 Rest of the world financing schemes (non-resident) available. These expenses are missing, but it is assumed that the amount in comparison to the the total of health accounts is negligible.

On accuracy, OOP spending is the most difficult item to estimate. As Liechtenstein does not have any information from surveys about OOP, the Statistical Office estimates this amount on basis of the OOP per capita in Switzerland. It's not easy to assess how close this estimation is from the true value, but e.g. from EHIS it is known that the health systems in Switzerland and Liechtenstein are very similar and that people have similar health problems and similar health behavior.

Allmost all data is based on government and municipal accounts, annual reports and operational accounts of health insitutions. Subsequently most expenses are accurate.

The main imprecise value are OOP expenses, as an important part of them is estimated on the basis of Swiss OOP expenditure per capita. Nonetheless, due to similar living costs, similar health system and similar health condition/behavior of inhabitants, the estimation is supposed to be good.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Some health expenses occur in two data sources, e.g. government contributions: they are found in government accounts and the health institutions (nursing home). Statistics Liechtenstein does not exclude this data at the very beginning, but uses the information in both sources to check the data quality.

Later in the statistical analysis the amounts are displayed in a table and it is checked if only one side is used for calculating health accounts. Subseqently, over-coverage or double-counting is not an issue.

Not applicable as no survey data is processed.

Not aware of any measurement errors.

Not applicable.

Not applicable.

Not applicable.

As all data is displayed detailed in time series before health accounts are calculated, wrong coding and other errors should be detected beforehand.

However, if rather small amounts are coded incorrectly, random errors still can occur.

Not applicable.

Not applicable.

Not applicable.

Revisions are made if incorrect classifications have been used or if Switzerland is changing their methods concerning health expenses which have been used to generate estimates for Liechtenstein. The general idea is that revisions should not be made every year, but as health accounts are fairly new for Liechtenstein and especially OOP-practices are improved, revisions are necessary relatively often (almost every year).

Adjustments for the reference years 2013, 2014 and 2015 on May 4th 2018.
Some expenses for health accounts in Liechtenstein are estimated on basis of Swiss data. If the Federal Office for Statistics in Switzerland improves their estimates, changes in Liechtenstein are often necessary as well. For the reference years 2013, 2014 and 2015 the following adaptions (A+B) have been made:

A) Estimates of expenses for drugs in hospitals:
As of lately information about expenses for drugs in hospitals is available for Switzerland. Hence the amount for Liechtenstein has been estimated on basis of percental distribution of Swiss data. Afterwards expenses for drugs, which have been up to now included in according outpatient or inpatient expenses in hospitals (HC.1, HC.2, HC.3 incl. subcategories), have been subtracted in those categories and assigned to drugs (HC.5.1).

B) Improved estimates of out-of-pocket expenses:
The Federal Office for Statistics in Switzerland has improved their estimation methods for out-of-pocket expenses. Firstly expenses for therapeutic appliances have been estimated and added and secondly the category HC.5 Medical goods has been reduced. The latter was done because expenses for the fire department have been accidentally included.
These adjustments in the out-of-pocket expenses changed the overall amount of health accounts in Liechtenstein for the years 2013 until 2015, the sum changed between -0.1% and 3.5% per year.

C) There is one institution in Liechtenstein which activities were formely coded as HC.3.1 and now have been recoded as HC.2.1. This has been changed for the years 2013-2015.

This information is well documented in our national publication Gesundheitsversorgungsstatistik 2017, Chapter Methodik und Qualität, Wichtige Hinweise, page 48ff:

https://www.llv.li/files/as/igv-2017.pdf

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.

T+17 months.

Not applicable.

Data was sent on time.

Data was sent on time.

Not applicable at national level.

Not applicable.

Breaks in time series resulting from methodological changes

See 8.2.

In general, SHA data is reconcilable to finance data in other health statistics, such as health insurance. However, as SHA has a much broader focus, figures are difficult to compare.

Not applicable.

Not applicable.

SHA data is published yearly in "Gesundheitsversorgungsstatistik" [in German only]:

https://www.llv.li/inhalt/117530/amtsstellen/gesundheitsversorgungsstatistik

SHA data is published yearly and available in following formats:

a) Gesundheitsversorgungsstatistik (German only), pdf-document:

https://www.llv.li/files/as/igv-2017.pdf

b) All tabels in excel:

https://www.llv.li/inhalt/117530/amtsstellen/gesundheitsversorgungsstatistik

c) In addition data is published in interactive datacubes (German and English):

www.etab.llv.li

SHA data is available on www.etab.llv.li

Information is not available.

Microdata is not published.

Not applicable.

The publication "Gesundheitsversorgungsstatistik" contains the chapter "Methodik und Qualität" which provides general information about SHA methodology for Liechtenstein data.

https://www.llv.li/files/as/igv-2017.pdf

In addition, as SHA data is rather complex, there is a separate, detailed method-documention online available:

https://www.llv.li/files/as/methodische-erlauterungen-gesundheitsausgaben2016.pdf

Both documents are only available in German.

None.

Not applicable.

Not applicable.

Office of Statistics needs around 200 hours for calculating Health Accounts for Liechtenstein. These hours also include the national publication "Gesundheitsversorgungsstatistik", but by far most work is directly related to health accounts.

As most financial data is obtained from administrative data, the burden on respondents is not significant. There are just a small number of questions to clarify specific details. No surveys are conducted.

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

Concerning health accounts there are no confidentiality problems. There is only one institution, which - with little background knowledge - could be seen in Liechtensteins Health Accounts data. Therefore Office of Statistics asked this institution directly for permission before publishing detailed data.

1) Liechtenstein is a small country with less than 40,000 inhabitants. Therefore a lot of health services are bought abroad (Switzerland, Austria), e.g. around 75% of hospital expenditure is included in the category "Rest of the World". This fact needs to be taken into account when looking at the Health Accounts tables, because this might explain a lot of differences in comparison to other countries.

2) Cost for day care (day curative care, day rehabilitative care, day long-term care) are included in the according outpatient positions.

3) In order to be aligned with non-monetary data, pediatricians are included in the category 'specialists'.

4) In principle the health system in Liechtenstein is very similar to the Swiss one, hence some information which is not available for Liechtenstein (e.g. OOP) is estimated based on the Swiss expenditure per capita.