Ministry for Health

Health Information & Research Directorate

Directorate for Health Information and Research,

95, Telghet Gwardamangia, Gwardamangia

Malta

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, household etc). 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.

Detailed data based on SHA 2011 is available for the reference years 2014 and 2015. At the time of submitting this quality report, the data for the reference years 2016 and 2017 are being analysed by Eurostat.

Not applicable.

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

-          Surveys/census: 1

-          Public administrative records: 0

-          Financial reports: 2

-          Other: 0

Surveys/censuses

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.

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)

4- In addition to the validation process described above, the local coordinating unit responsible for collating the data, carries out various exercises and analyses to ensure consistency and accuracy of the data provided by the different entities forming part of the Ministry for Health. One to one meetings are organised with respective entities and the provided data is discussed, to detect possible one-offs items. Data is also analysed by studying trends, growth patterns and outlier entries. An external consultant specialized in Health Economics, is engaged by the Ministry to analyse the data at macro-level. 

SHA data is compiled both by a bottom-up approach as well as by a top-down approach, depending on the funding 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. In other instances, data is apportioned between cost centres/departments based on available information within the particular institutions. 

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.

Data compilation for private health care expenditure:

HCxHF: Data is provided by the National Health accounts to come up with the respective apportionments for out of pocket expenditure and voluntary health care insurance expenditure. 

HCxHP: The total private health expenditure information is obtained from the data for private hospitals according to the NACE categories. The sub-components are calculated on the basis of information provided by the private hospitals on bed days and type of expenditure. 

HPxFP: The apportionment is based on the basis of ratios obtained from expenditure patterns within the public hospital sector for the various FP components. 

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.

Data is collected through a web-based collation system which has inbuilt checks and balances to ensure that data is validated at source, and ends up at Head Office already filtered and ready for use for consolidation purpose. Each Financial Controller of the different entities forming part of the Ministry for Health is responsible for the collation and compilation for the data inputed by his/her entity. Each entity is obliged to follow the SHA 2011 methodology. Regular meetings are organised between Head Office, the Health Information & Research Directorate and the respective entities, particularly with Mater Dei Hospital being the main provider of healthcare in Malta. In cases of particular clarifications provided by Eurostat, these are disseminated back to each entity by the Head Office.

Once consolidation is finalized, data is checked by Head Office and reviewed by an external consultant. Following the go ahead by the Director General of Finance and Director of the Health Information & Research Directorate, the SHA file is uploaded via eDAMIS portal.

Data is based from already audited financial information or data available from the system used by the Treasury Department. This serves to ensure that the main items of expenditure are reliable and not subject to assumptions or subjective evaluations.

Following recent meetings with Eurostat, it is planned that Malta conducts a reconciliation exercise between SHA and National Accounts.

International

European Commission;

EU Institutions;

International Organisations.

National

Ministry for Health Top Management;

Other Ministries;

Consultants in Public Health;

Social Partners (ex. MCESD);

Academic Institutions;

General Public;

Non-Governmental Organisations.

Due to the small size of the country, in case of particular needs from entities not satisfied by the data published on the SHA tables, the Ministry for Health will discuss particular needs and provide the data accordingly (outside the scope of SHA). 

At the moment no user satisfaction surveys are done on the SHA. 

Malta is providing almost all the compulsory data stipulated by the Commission Regulation 2015/359, relevant to the healthcare system that exists in the country.

There is a deviation in the supplementary table (not required by the Commission Regulation) on capital formation in which the Ministry is not reporting the gross fixed capital formation but only the capital expenditure incurred during the year.

Around 80 % of compulsory variables have been provided.

As regards public health expenditure the Directorate is confident that data provided is in general accurate, since the main variables are sourced from financial reporting of our entities. As regards other variables, since assumptions have to be made, the accuracy of the figures provided may be affected.

As regards public expenditure no sampling is done.

As regards private expenditure data given that is based on national accounts data, which is in turn based on administrative data and the Household Budgetary Survey (HBS). The data within the private expenditure component is subject to any sampling errors within the source of the data, i.e. the HBS primarily. 

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

We are not aware of any measurement errors.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

The disaggregation within the private sector data is based on information obtained from the main private sector provided of health care services (such provider accounts for around 70% of the total private sector provision of health care).

Not applicable.

The SHA submissions covering financial years 2014 and 2015 were amended as per recommendations and feedback received from Eurostat.

SHA data submitted for reference years 2016 and 2017 are being analysed by Eurostat under the 2019 data collection exercise.

The SHA submissions covering financial years 2014 and 2015 (submitted on 22nd Jan 2019) were amended as per recommendations and feedback received from Eurostat.
At time of submitting this quality report, the SHA submission for 2016 and 2017 are being analysed by Eurostat.

In the original SHA submissions, out-of-pocket expenditure was not included. Eventually, following discussions with Eurostat, this material amount of expenditure was included in the final submissions for reference years 2014 and 2015.

The submissions for the reference years 2016 and 2017 were included in the first submission.

Official public health expenditure is available after three months from the end of financial year.

The private health expenditure data is available with a lag of at least 1 year. 

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.

Approval of extensions were obtained from Eurostat following a justified request from the Ministry for Health.

Data for reference years 2014 and 2015 were accepted as final for publication by Eurostat on 4th March 2019.

A number of reasons were behind the lack of punctuality, especially regarding the financial year 2014. These were mainly related to lack of human resources and systems to collate data from differenct sources. There were also a number of new top financial officers in different entities, responsible for the collation of data.

Unless there were no extraordinary events, (such as IT issues etc) the Directorate did the utmost to respect the extensions granted by Eurostat. 

Not applicable at national level.

Not applicable.

The data available covers 2014 and 2015. Thus, no comparison with previous SHA submission was possible.

However, in both cases the public health expenditure was analysed against information published by Malta' Treasury Department to ensure that the overall figure is in line with previous available data.

Not applicable.

It is planned that the private health expenditure provided in SHA will be reconciled to other statistics collated by Malta's National Statistics Office.

Not applicable.

It is planned that the private health expenditure provided in SHA will be reconciled to other statistics collated by Malta's National Statistics Office.

Atypical entries

No press released is issued.

No press released is issued.

No online database is available.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Such documentation is not available.

Almost all the metadata information requested is provided.

The metadata file is not available to the public.

Restricted from publication.

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

Not applicable since data is not yet being published by the Ministry for Health. Data is only available through Eurostat. Consequently, the Eurostat confidentiality policy applies.

None.