National Institute of Statistics (NIS), ROMANIA

Demography, Health, Culture and Justitice Statistics - Department of Studies, Demographic Projections and Population Census

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 2017 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, section O: public administration and defence; compulsory social security; other NACE of enterprises that provide health care to employees in their own medical offices or that purchase health care services from sanitary units, for their employees.

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 is available, under the SHA 2011 methodology, for the period 2011-2016.

Not applicable.

Several data sources are used (as of April 2019):

-          Surveys/census: 3

-          Public administrative records: 7

-          Financial reports: 4

-          Other: 2

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.

 NIS Romania receive data from administrative and survey sources:

- the National Health Insurance House (NHIH) send NIS data regarding amounts contracted by the sanitary units by ICHA codes.

- data on budgetary execution of revenues and expenditures of public institutions with a health network are collected and publicly available on a Ministry of Finances(MoF) portal (at COFOG 3 level), the MoF sends to NIS the aggregated budgetary execution for the Local Administrations. These data, together with MoH and NHIH data, are used by NIS to consolidate the budget.

- data on budgetary execution of revenues and expenditures of public network hospitals is collected and send to NIS by the Ministry of Health. The expenditures are available by source of revenues (state budget, local budget and social security, other own revenues revenues). 

- the MoH sends to NIS data regarding expenditures for the Annual National Health Programme by ICHA code by the end of year T-1.

- data used for SHA indicators and estimations from the NIS survey "Activity of Sanitary units - SAN" is available for the previous year (T-1) for non-expenditure data and for T-2 for expenditure data.

- Household Budget Survey is conducted by NIS and provides data for SHA regarding average monthly expenditure of a household for a list of health services and the total number of households.

- data regarding private health expenditure is collected by the National Financial Authority based on a NIS questionnaire and sent to NIS by December T-1.

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 tools provided by Eurostat, NIS Romania performs other checks on data sources and growth rates, identifies policy changes to explain changes in data trends for specific type of providers, services or financing agents before compiling the SHA tables.

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.

At national level, the ICHA is not used for classifying services and providers. NIS allocates ICHA codes for the national types of sanitary units. For hospitals, NIS introduced in the annual "Activity of Sanitary Units" codes for the types of hospitals of ICHA, these information for each hospital in Romania is used for all other data provided by the Ministry of Health and Ministry of Finance. 

Health expenditure data is diseminated in a publication based on SHA data tables but providing methodological information on how these data are linked with the national health system.

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.

NIS Romania compiles the data starting from healthcare unit or ministry level which are validated either by NIS (in the case of surveys) or by institutions providing administrative data. Using non-expenditure data or average costs can lead to over-estimation or under-estimation of some indicators where data are missing, but the base data used has a degree of reliability that we are expecting a good quality of the data resulted. NIS is making efforts to identify new high quality data sources and introduce SHA methodology in the national statistics in order to provide quality data.

Main users of SHA data in Romania are the Ministry of Health and other central government institutions/ministries, researchers and journalists. The Eurostat database is often used by users to obtain SHA data.

Currently there is no specific user satisfaction accounting, but NIS is providing methodological suport and specifications to all users that are requesting the data. Also, communications are maintained with the central government institutions that are both providers and users of the SHA data. 

Below are the information regarding the completeness of Romania SHA data.

Table HCxHF = 67.0%

Table HCxHP = 77.3%

Table HPxHF = 62.5%

The accuracy of the base statistics used in compiling SHA data is of good quality as the data sources are mainly exhaustive and validated. Some over-estimations or under-estimations can occur when non-expenditure data is used. 

Data are underestimated for expenditure of the NPISH financing schemes that include expenditure of the main non-profit organisations for which public financial and non-financial reports were available giving the posibility of identiffying health care related data.

Rest of the world financial schemes data sources were not identified and we cannot estimate if these expenditure can be included in other schemes.

The administrative data used are exhaustive.

Not applicable.

Non-resident expenditure are excluded. SHA data does not cover informal payments.

Double counting is eliminated in the base calculation of the public administration and social health insurance expenditure.

Non-resident expenditure are not included in the private insurance scheme (HF.2.1) and in the household out-of-pocket payment schemes (HF.3) and is excluded from the social health insurance scheme (HF.1.2).

Informal payments are not included in the SHA data.

None.

None.

None.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

No model is used.

Not applicable.

According to NIS revision policy, revisions for previously transmitted data are sent together with data for the reporting year.

According to NIS revision policy, revisions for previously transmitted data are sent together with data for the reporting year.

The last revision was transmitted in 2019 for the period 2011-2016. The revisions averaged -0.02% for 2014-2016 and represents the exclusions of expenditure for healthcare services of non-residents that were covered by the social health insurance fund.

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.

Romania does not publish first results.

Final results are published in December for the year T-2.

The National Institute of Romania complies with the Commission Regulation 359/2015 transmission deadlines.

Delivery to Eurostat done by 30 April for T-2.

Not applicable at national level.

Not applicable.

Breaks in time series resulting from methodological changes

With the few exceptions mentioned, data series are comparable for 2011 to 2017 reference years.

Although SHA and ESSPROS data intersect in respect to the data sources used (allowances for persons accompanying the severe visual impairment, general government and social health insurance scheme, expenditure in the elderly persons residential homes and residential units for persons with disabilities), the compilation of the two are different. The ESSPROS and SHA teams are colaborating and identified the intersections of the two datasets.

Not applicable.

The SHA and National Accounts data are mostly comparable regarding COFOG total expenditure, differences appear in the COFOG structures as SHA is compiled (for HF.1.1 and HF.1.2) in a bottom-up approach. This leads to some differences in the distribution in COFOG categories. 

Other differences comes from the broader scope of the SHA leading to the inclusion of health related expenditure in social residential institutions, of occupational healthcare expenditure.

Internal consistency of the data is checked with the tools provided by Eurostat but NIS Romania also performs checks of the datasets used for every scheme (see point 3.4).

The Healthcare Expenditure Accounts data are not included in a news release.

The Healthcare Expenditure Accounts are disseminated through an annual publication, "The System of Health Accounts in Romania", in December of year T for the year of reference T-2. The publication include T-2 data tables and analysis of data trends in the period of available SHA data. Also, a methodological analysis of SHA and national sources and data used for compilation is included.

http://www.insse.ro/cms/ro/content/studiu-sistemul-conturilor-de-s%C4%83n%C4%83tate-%C3%AEn-rom%C3%A2nia (only available in Romanian)

SHA data is not available in the NIS online database. Users are directed to the online publication or Eurostat database.

The number of consultations of the online publication is not currently available.

Not applicable.

Indicators based on SHA data are published in the Annual Report on the Implementation of the National Health Strategy (http://www.ms.ro/wp-content/uploads/2016/10/Raport-Implementare-SNS-2015.pdf).

Methodological description of the compilation of SHA data is included in the annual publication "The System of Health Accounts in Romania".

Specifications on data sources, data management are available in the publication "The System of Health Accounts in Romania" (see point 9.2) and in the metadata available on Eurostat database.

The metadata on Eurostat database includes the specifications of data sources and estimations used in compiling the SHA tables.

NIS does not have information regarding consultations of the SHA metadata.

In the reference period the Health Expenditure Accounts were compiled, at NIS level, by 2 experts. 

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

The Health  Expenditure Accounts uses aggregated and public available data (healthcare units and survey data) and no personal information is used thus no confidentiality procedures are applied.

NPISH financing schemes are underestimated: expenditures included represent funds identified in the activities reports, available to the public, of the main fundations and non-profit associations which conducts health activities in Romania.

Expenditures for laboratory services (HF.1.1 and HF.3.1) could include imaging services that cannot be identified.