Statistics Poland

Social Surveys Department – Health Statistics Division

Niepodległości 208 Av. 00-925 Warsaw, Poland

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. 
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.

One of the important factors concerning SHA2011 data collection is the fact that Statistics Poland is using the cash method.

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 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 caregivers 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" (only healthcare section).

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.

Detailed data according to SHA 2011 is available from 2013-2016 for Poland. Main aggregates are also available for 2017.

Not applicable.

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

-          Surveys/census: 3 (household budget survey, module survey “Health care in households”, non-profit institutions survey)

-          Public administrative records: 9

-          Financial reports: 1

-          Other: 0

Public administrative records

Financial reports

Annual.

Annual records on activity of ministries (Ministry of Health, Ministry of National Defence, Ministry of Justice, Ministry of Social Policy, Ministry of the Interior) and other institutions (National Health Fund, Social Insurance Institution, Agricultural Social Insurance Fund, National Fund for Rehabilitation of Disabled) are submitted annually in a standardized format to Statistics Poland. 

Rb-28 Annual report on realization of state budget expenditure plan, Rb-28s Annual report on realization of territorial self-government budgetary units’ expenditure plan is obtained from Statistics Poland Macroeconomic Studies and Finance Department.

Expert estimations on the basis of the yearly conducted household budget survey and the module survey “Health care in households” carried out every 3 years.

Expert estimations on the basis of the non-profit institutions' survey (SOF).

Expert estimations on the basis of the number and price of the preventive medical examinations of working persons. (MZ-35A)

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)

In addition to the validation features provided by the JHAQ, Statistics Poland carries out several other steps to check and validate its SHA data. Time series for each data source/calculation step are analyzed for trends, growth rates and anomalies.

Growth of aggregate data is decomposed in its single elements to detect possible miscalculations. New entries and revisions are double-checked and analyzed in detail. Consistency between dimensions is achieved as every single calculation is coded with all three corresponding dimensions. Results of years that are not re-transmitted/re-published are also calculated even if there is no change and these results are compared with calculations in previous years to secure consistency of the calculation methods over time.

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.

Statistics Poland publishes data at the national level according to international SHA 2011 methodology without changes.

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.

Law on official statistics imposes the obligation to look after quality under the Code of Practice: Art. 25a. The President of Statistics Poland performs tasks specified in the Act, follows the principles of professional independence, impartiality, reliability and responsibility for the high quality of national and international statistics, under the European Statistics Code of Practice referred to in art. 11 of Regulation (EC) No 223/2009 of the European Parliament and of the Council of 11 March 2009 on European statistics and repealing Regulation (EC, Euratom) No 1101/2008 of the European Parliament and of the Council on the transmission of statistical data to the Statistical Office of the European Communities subject to the principle of confidentiality, Council Regulation (EC) No 322/97 on Community Statistics and Council Decision 89/382 / EEC, Euratom establishing a Committee for the Statistical Programs of the European Communities (OJ L 87/3131, 31.03.2009, page 164), "Regulation No. 223/2009".

SHA was introduced as a survey for the annual program of statistical surveys approved by Prime Minister's Office and imposes an obligation to provide data (within a given scope and structure) for the purposes of JHAQ.

The best-developed classification is HF.1 public / compulsory expenditure schemes because Health Statistics Division uses detailed reports of financing agents based on reports on implementing material and financial plans, reports on implementing the state budget (RB-28), reports on implementing the budget of local government units (RB-28s). Health Statistics Division works closely with the largest financing agent (National Health Fund) to maximize the precision of classifying individual expenditure.

The greatest difficulty is estimating by private health expenditure, including cost sharing.

The main recipients of data from NRZ are financing agents, i.e. ministries, Social Insurance Institution, Agricultural Social Insurance Fund, etc. Data recipients are also media, institutions conducting scientific, educational and analytical activities and students. Some disadvantage for data users is a two-year delay in the publication of data, which makes data become potentially less attractive for users who want the latest data. Another problem could be a complex methodology (e.g. ICHA-HF) that requires a lot of time to understand its nuances.

HF.4 is unavailable due to the lack of data sources.
HF.3 - no data on cost sharing.

Almost 100% of mandatory variables of the three dimensions according to Commission Regulation 359/2015 that are relevant/occurring in the Polish health system (for exceptions see 5.3).

The overall accuracy of Polish SHA data can be considered to be quite good. In many cases we avoid double counting, e.g. data provided by Ministry of Family, Work and Social Protection coincides with RB-28 report, non-profit expenditure coincides with NFZ expenditure, etc. Health Statistics Division compares the expenditure of ministries and other institutions with the reports on the use of the state budget.

Not applicable.

There is a sampling error in Household budget surveys used as a basis for the calculation of OOP expenditure. However, the HBS data undergoes further calculation for the NHA purpose. In the table below: selected indicators

All cases of double counting of expenditure are eliminated. An example can be non-profit expenditure and NFZ expenditure, which partly overlap. 

Other examples are local governments and subsidies on particular levels of local governments are also excluded. We take into account only the final financing agents.

Not applicable.

Health Statistics Division is not aware of any measurement errors.

In HBS, 2017 response rate amounted to 37,7%.

In HBS, 2017 response rate amounted to 37,7%.

Not applicable.

No such errors.

No such errors.

Not applicable.

Not applicable.

Generally, when calculating national health account for each subsequent year, the categories of expenditure are compared with previous periods and checked for their accuracy and coherence due to current knowledge. In justified cases and, as far as possible, data for previous years are revised in order to achieve comparability of data over time.

Generally, when calculating national health accounts for each subsequent year, the categories of expenditure are compared with previous periods and checked for their accuracy and coherence due to current knowledge. In justified cases and, as far as possible, data for previous years are revised in order to achieve comparability of data over time.  

Difficult to calculate.

There were no deviations from deadlines in the reference period.

 Thirteen months.

Statistics Poland transmits SHA2011 data for t-2 and estimations t-1 annually via EDAMIS by end of April year t. The national publication takes place at the end of June for t-2.

There were no deviations from deadlines in the reference period.

Not applicable.

Polish National Health Account is developed from the side of agents, which expenditure covers the whole area of Poland. There are no regional accounts because of the lack of regional data.
International comparisons are possible in all major classifications: ICHA-HC, ICHA-HP, ICHA-HF and are available in OECD, Eurostat and WHO databases:

https://stats.oecd.org/   (OECD)

http://apps.who.int/nha/database/Select/Indicators/en  (WHO)

https://ec.europa.eu/eurostat/data/database (Eurostat)

Not applicable.

Data according to SHA 1 is available from 2004 to 2012 and is comparable in such timeframe. Data according to SHA2011 is available and comparable in the 2013-2017 timeframe.

Breaks in time series resulting from methodological changes (SHA1.0 to SHA2011 transition)

Definitive break in the series was caused by the implementation of SHA 2011 revision.

SHA and ESSPROS cannot be mapped from one to another, however, some SHA data referring to LTC is used for ESSPROS calculation.

Not applicable.

Statistics Poland publishes the President's announcement regarding the most important NHA aggregates:

https://stat.gov.pl/sygnalne/komunikaty-i-obwieszczenia/lista-komunikatow-i-obwieszczen/obwieszczenie-w-sprawie-narodowego-rachunku-zdrowia-za-2016-rok,283,5.html

https://stat.gov.pl/sygnalne/komunikaty-i-obwieszczenia/lista-komunikatow-i-obwieszczen/obwieszczenie-w-sprawie-narodowego-rachunku-zdrowia-za-2015-rok,283,4.html

https://stat.gov.pl/sygnalne/komunikaty-i-obwieszczenia/lista-komunikatow-i-obwieszczen/komunikat-w-sprawie-narodowego-rachunku-zdrowia-za-2014-r-,283,3.html

Health and health care in 2017:

https://stat.gov.pl/obszary-tematyczne/zdrowie/zdrowie/zdrowie-i-ochrona-zdrowia-w-2017-r-,1,8.html

No online database at the national level.

Restricted from publication.

Microdata is not disseminated.

Not applicable.

 The methodology is described, quite generally, in an information note: 

https://stat.gov.pl/obszary-tematyczne/zdrowie/zdrowie/narodowy-rachunek-zdrowia-za-2016-rok,4,9.html

More detail in the publication Health and health care in 2017:

https://stat.gov.pl/obszary-tematyczne/zdrowie/zdrowie/zdrowie-i-ochrona-zdrowia-w-2017-r-,1,8.html

Not available.

Not available.

Not available.

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

No further comments.