Statistics Lithuania

Social Protection, Health, Education and Culture statistics division

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 according to the SHA 2011 for the years 2007–2016 are available.

Not applicable.

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

-          Surveys/census: 4

-          Public administrative records: 5

-          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.

Data from institutions operating national administrative data sources (National Health Insurance Fund, Institute of Hygiene, etc.) are collected by Statistics Lithuania according to the inter-institutional agreements and provided by e-mail. Primary data from statistical surveys are obtained from corresponding units of Statistics Lithuania according to the schedule of internal data exchange.

In Statistics Lithuania the results of data compilation are compared with the results of the previous year. Outliers are identified and analysed. In case of significant discrepancies, survey or administrative data managers are contacted, and reasons are determined (changes in the legislation, implementation of new services and /or goods, changes in financing, etc.). If inaccuracies are detected, data are corrected.

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)

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, and by providers of services/goods. 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 as well as  ESS Quality Assurance Framework. Procedures are in place to plan and monitor the quality of the health care expenditure statistical production process.

In 2007, a quality management system, conforming to the requirements of the international quality management system standard ISO 9001, was introduced at Statistics Lithuania. The main trends in activity of Statistics Lithuania aimed at quality management and continuous development in the institution are established in the Quality Policy. Monitoring of the quality indicators of statistical processes and their results and self-evaluation of statistical survey managers is regularly carried out in order to identify the areas which need improvement and to promptly eliminate the shortcomings.

The main users of statistical information are State and municipal authorities and agencies, the media, research and business communities, students, whose needs are satisfied without a breach of the confidentiality principle.

From 2005, user opinion surveys have been conducted on a regular basis. Official Statistics Portal traffic is monitored, website visitor opinion polls, general opinion poll on the products and services of Statistics Lithuania, target user group opinion polls and other surveys are conducted. In 2007, the compilation of a user satisfaction index was launched. The said surveys are aimed at the assessment of the overall demand for and necessity of statistical information in general and specific statistical indicators in particular.

For more information on user surveys and their results, see section User surveys on the Statistics Lithuania website.

Statistics Lithuania transmits the data to Eurostat in compliance with the Commission Regulation 359/2015.

100%

Statistics Lithuania doesn't conduct a special survey for the Health Expenditure data; therefore, an accuracy of the results very much depends on the overall quality of data sources used. Primary data from administrative sources and statistical surveys are classified using ICHA codes and aggregated; in some cases estimation methods are applied. The results are analysed taking into account several aspects –changes of legal base developing the health system,  changes in structure and scope of services of particular provider, information from different sources about the particular item of accounting.  Lacks in accuracy are observed in the fields where appropriate data sources for specific categories are missing or are not comprehensive enough. However, the analysis of new potential sources that could supplement existing data is performed continuously.

Not applicable.

Not applicable.

No sample estimates are used. Coverage error is based on the lack of data or insufficient comprehensiveness of it in the available data sources.

Coverage error is observed in estimation of pharmaceutical expenditure, because the detailed information on the structure of goods provided by retailers and others providers of medical goods is not available. Some non-medical expenditure is covered in this item. Expenditure on Health care goods and services by non-residents are included in domestic provider revenues, because no relevant data source is available. The underground / informal / illegal health care goods and services in the data collection are also not included due to the lack of the data source.

Over-coverage rate of inclusion of services and goods provided to non-residents and non-medical goods provided by retailers is not calculated due to the lack of data sources.

Information on common units from administrative sources and surveys are collected and analysed at the primary level (i. e. data on employment and wages in the particular hospital are obtained form the Compulsory Social insurance fund database, data on compensations for services paid from the Compulsory Health insurance fund budget is obtained from the Compulsory Health Insurance information system; while the data on out-of-pocket payments for services provided - from the Survey of Social and Cultural servicesl, etc.), in preparation of the results one unit is accounted once.

Measurement error can be considered to be relatively minor in terms of the volume of health expenditure; it is corrected immediately after the recognition.

Not applicable.

Not applicable.

Not applicable.

In order to avoid error in data coding all information form different sources on the particular unit of accounting is collected.

Not applicable.

Not relevant.

Not applicable.

The data of T-2 and estimates of T-1 are always considered as preliminary. Revision is made if any new data are available in the currently used data sources or a new data source is identified.
Re-calculation or re-allocation of some expenditure categories is also made according to the recommendations of the IHAT during the validation procedure of data provided.

The data of the year 2015 was revised after the analysis of activities and re-coding of providers; the revision mostly affected the item HP.5.2.1.  

The difference between a later and an earlier estimate of the health expenditure for the year 2014 was 0,0%, for 2015 -0,3%, for 2016 0,1%.

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.

Statistics Lithuania publishes statistical information on the Official Statistics Portal according to an Official Statistics Calendar, following the Official Statistics Dissemination Policy Guidelines and Statistical Information Preparation and Dissemination Rules.

A news release on healthcare revenues and expenditure (preliminary) is published by Statistics Lithuania no later than 12 months after the end of the reference period.

Final result is published no later than 24 months after the reference year.

Statistics Lithuania complies with the Commission Regulation 359/2015 transmission deadlines.

Transmission to Eurostat: 31 March in year t for data on year t-2 that is for 1 month earlier than the deadlines indicated in the Commission Regulation 359/2015.

Not applicable at national level.

Not applicable.

Data calculated according to the SHA 2011 metohodology are comparable over time.

Data according to SHA 2011 is available for the years 2008–2016 and comparable over this time frame.

Not applicable.

Atypical entries:

News release "Health care expenditure" is published on the Official Statistics Portal according to the annual calendar, no later than 12 months after the end of reference year.

Statistical Yearbook of Lithuania

Official Statistics Portal Indicators database - Population and social statistics - Health - Health care - Healthcare revenues and expenditure

Information not available.

Not applicable.

Results of SHA data compilation is yearly provided to National Accounts division, sent to the Ministry of Health (comparisons of two years data) as well as to the Institute of Hygiene and the National Health Insurance Fund.

Methodology of health expenditure data compilation (in Lithuanian) is agreed by the Methodological Commision of Statistics Lithuania, approved by the Order of Director General and publicly available on the Official Statistics Portal - Metodikos.

Standardized metadata is published in the Indicators Database of the Official Statistics Portal and updated yearly.

A separate Quality report is not prepared. The main information on health expenditure data are provided in the standard metadata file mentioned in point 9.6.

Metadata is prepared and published according to the requirements applied to all surveys and data compilations conducted by Statistics Lithuania.

Information not available.

Cost of production of statistical product in Statistics Lithuania for the year 2016 was 23,50 thousand EUR. Information on cost of production and provision of data necessary for SHA data compilation in other institutions are not available.

Data collection does not generate additional individual burden to the respondents, because only secondary data sources are used to the fullest extent possible (administrative databases, financial records and data from statistical surveys already conducted for other purposes). 

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

In the process of statistical data collection, processing and analysis and dissemination of statistical information, Statistics Lithuania fully guarantees the confidentiality of the data submitted by respondents (households, enterprises, institutions, organisations and other statistical units), as defined in the Confidentiality Policy Guidelines of Statistics Lithuania.

Description of Statistical Disclosure Control Methods, approved by Order No DĮ-124 of 27 May 2008 of the Director General of Statistics Lithuania.

Integrated Statistical Information System Data Security Regulations and Rules for the Secure Management of Electronic Information in the Integrated Statistical Information System, approved by Order No DĮ-42 of 20 February 2015 of the Director General of Statistics Lithuania (only in Lithuanian).

No additional comments.