Statistics Norway

Division for National Accounts 

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.

Figures based on the latest version of the OECDs A system for health accounts (SHA 2011 methodology) was published for the first time in 2015.

Not applicable.

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

-          Surveys/census: 0

-          Public administrative records: 0

-          Financial reports: 1

-          Other: 3

Financial reports

Other

Annual.

The health accounts are based on source statistics collected by other divisions in Statistics Norway. There is no separate data collection for the compilation of the health accounts.

The health accounts are to some extent based on more detailed statistics than what is relevant for the national accounts.

The health accounts are based on information in the Norwegian national accounts, and revisions of the national accounts data will consequently influence the health accounts.

National accounts - revision strategy

The national accounts are compiled in different versions: annual accounts are normally compiled in three consecutive preliminary versions and a final one; and occasionally a main revision later on. Main revisions will be carried out every 5-7 years.

The degree of revisions will depend on the availability of new and more comprehensive data sources. For instance, the introduction of the new system developed for reporting data from local to central government (KOSTRA), resulted in improved municipality data and subsequent revisions of the local government figures in the national accounts.

The main part of the compilation of the health accounts consists of linking data from the national accounts to the health accounts according to the classifications defined in the OECD manual. In some cases the national accounts provide data at a more aggregate level than what is needed for the health accounts. In those cases extended data sources are used to identify the necessary details. For instance, data from the Norwegian Patient Register (NPR) is the basis for distinguishing between expenditures on in-patients and out-patients in hospitals.

The Norwegian health accounts provide data in current and constant prices. The calculations in constant prices are based on the national accounts methods. This means that the constant price estimates are calculated with prices from the previous year. The calculation is carried out at a detailed level, and then chained to the present reference year. The chaining is carried out separately for all items.

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. The results of the several calculations are then aggregated.

To gain the differentiation between the different SHA-dimensions (especially HC and HP) quotas and pro-rating and utilisation keys are applied on some spending items. For some spending items it is necessary to extra-/intrapolate data as there is no up-to-date data available or data is missing for certain years. For some other spending items, estimation methods have to be applied.

Several methods are normally used for estimations:

• Balancing item/Residual method: For example, if data are available from the financing side, which permit accurate estimation of the flows to a provider or function, then an acceptable estimation method is to subtract these expenditure flows from the total revenues, and derive the expenditure flows from the unmeasured financing scheme as a residual.
• Pro-rating/Utilisation key: Typically in the absence of direct spending data, a utilisation key linked to the proportion of resources used can be constructed in order to distribute e.g. aggregate provider spending across functions. For every key a fraction of total utilisation within the cost-unit is assigned: fractions in the key must add up to 100% of all care delivered by the cost-unit. Examples of utilisation keys are admissions, bed-days, contacts, staffing, etc.
• Interpolation/Extrapolation: In the absence of data for the period in question, missing values can be estimated using known data points.
• Or other.

Not applicable.

Authorities responsible for SHA data collection are working to ensure that the statistical practices used to compile national health accounts are in compliance with SHA methodological requirements and that good practices in the field are being followed, according to the methodology underlined in the SHA 2011 Manual and European Statistics Code of Practice respecting professional independence of the statistical authorities. Procedures are in place to plan and monitor the quality of the health care expenditure statistical production process.

The Norwegian health accounts are compiled using several different statistical sources. The statistical sources consist of data from establishments, enterprises, and households. In addition, different administrative registers are used. The uncertainty in the national accounts estimates is related to the errors in source data and the compilation methods. Uncertainty connected to the different statistical sources is usually described as part of the documentation of the sources. Several of the statistical sources used in the compilation of the national accounts remain preliminary for longer periods, as they require extensive analysis and numerous revisions before the final figures are known.

Since the system of national accounts is an integrated system containing routines for consistency checks of data, one assumes that the national accounts contribute to reduce the uncertainty in source data. On the other hand, the national accounts require the compilation of figures in areas where source statistics are limited or even lacking. In such cases figures are compiled using statistical methods, and hence subject to uncertainty.

Major users of the health accounts include the Ministry of Health and Care Services and subordinate institutions, other ministries, research institutes, international organisations, the media etc.

Not applicable.

For the compulsory variables of the HF categories the category HF4 “Rest of the world financing schemes (non-resident)” is missing because the data are not available. Also HF.1.2/1.3, HF. 2.1 and HF. 2.2, HF. 2.3 is missing because government health financing schemes are the major financing schemes in Norway. Funded mainly by the state budget ("statsbudsjettet" in Norwegian) and the health enterprises ("Helseforetak" in Norwegian, which get their funds from the state budget). Compulsory contributory health insurance schemes/CMSA does not exist in Norway.

For the compulsory variables of the HP adn HC categories all data are available.

HFXHP =75%

HCXHP=100%

HPXHF=75%

The quality of the Health Expenditure Accounts depends significantly on the quality of the statistics of national accounts. This means that detailed data from a range of sources integrated in the national accounts serve as a tool for presenting the health expenditure.

Not applicable.

Not applicable.

Not applicable.

Not aware of any coverage error.

Not applicable.

Not applicable.

We are not aware of any specific errors in reading, calculating or recording numerical values.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

March year T:
T-3: Final estimates. Based on annual national accounts.
T-2 : Preliminary estimates, will be revised the next year.

Data for 2015 are revised since last submission, and are now final. Data for 2016 and 2017 are preliminary and will be revised in the next submission.

Data is revised annually.

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 Norway transmits SHA data for t-2 annually to EUROSTAT by March 31st latest in line with the voluntary agreed deadline set-out by OECD for the JHAQ.

National publication takes place in Mid-March for t-2.

Not applicable.

Data was delivered before deadline.

8 days before deadline.

Not applicable at national level.

Not applicable.

Breaks in time series resulting from methodological changes

Not applicable.

Not applicable.

The health accounts are linked to the regular national accounts as a so-called satellite. This means that detailed data from a range of sources integrated in the national accounts serve as a tool for presenting the health expenditure.

Not aware of  any lack of coherence in the output of the statistical process. Internal inconsistency or between tables are due to rounding error. All data are based on the national accounts statistics.

In March every year.

Division for National Accounts publishes the SHA data at Statistics Norway's website every year: https://www.ssb.no/en/nasjonalregnskap-og-konjunkturer/statistikker/helsesat/aar

This is not available on Statistics Norway's website.

The number of consultations of SHA data tables on Statistics Norway's website are not available.

Not applicable.

Not applicable.

Not applicable.

Statistics Norways does not have available such documents.

Quality reports are based on self-assessment for the process.

Not available.

Statistics Norway uses data from the national accounts statistics which is published the year before and is using SAS to calculate most of the figures. Therefore, calculating the figures is not very time consuming.

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

According to the Statistics Act §2-6 information collected in accordance with any prescribed obligation to provide information, or which is given voluntarily, shall under no circumstances be published in such a way that it may be traced back to the supplier of any data or to any other identifiable individual to the detriment of the person concerned.

2011-2017: Consumption of fixed R&D capital are included in the current health expenditure.

2009-2012: Changes in the DRG system affected the split between HC.1.1, HC.1.2 and HC.1.3.3.