Statistics Sweden 

National Accounts Department

Statistics Sweden

National Accounts Department

Public Finance and Microsimulations

SE-70189 Örebro, Sweden

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 2001 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.

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.

2001 - 2017

Not applicable.

Several data sources are used (as of data notification in March 2019):

-          Surveys/census: 3

-          Public administrative records: 2

-          Financial reports: 2

-          Other/National Account data: 7

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.

The Swedish SHA data are to almost 100 percent based on official National Accounts data. To be able to report the data at SHA codes, National Accounts data needs to be distributed by keys. For the largest part of the expenditure the county councils annual accounts can be used. Those annual accounts are collected by Statistics Sweden for the purpose of National Accounts.

The 2019 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 adition to the validation performed by using the tools provided by JHAQ, Statistics Sweden perform a number of validation steps at an earlier stage. Time series for each calculation step are analysed for trends, growth rates and anomalies. Consistency between dimensions is achieved as each single calculation is coded with all three corresponding dimensions. Results of years that are not re-transmitted 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.

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 overall guidelines for Statistics Sweden’s quality management are described in Statistics Sweden’s quality policy. The quality policy covers statistical output, process and organisational quality.

Statistical quality

Issues related to the quality of the statistics and how it can be improved have always been central to Statistics Sweden. Information on the quality of the statistics to the users of the statistics is reported for the quality components relevance, accuracy, timeliness and punctuality, availability and clarity as well as comparability and coherence. These quality components are described in the quality handbook. In cooperation with international experts, Statistics Sweden has developed a system to evaluate the quality of the statistics. The evaluations are applied to Statistics Sweden’s most important statistical outputs.

Process quality

Statistics Sweden produces statistics in a process-oriented manner and increasingly uses standardised operating procedures, methods and tools. These are described in an internal information and support system. In March 2014, Statistics Sweden became certified according to the Standards ISO 20252 for Market, opinion and social research. The certification confirms that Statistics Sweden meets the fundamental quality requirements in the production of statistics. Statistics Sweden is conducting regular internal quality audits to validate and provide a basis for improvements in its operations.

Organisational quality

The framework consists of Statistics Sweden’s management process, which takes its starting point in how external requirements and requests are handled until finalised by external reporting. Planning and follow-up of operations, finances, and human resources as well as risk management ensure that the agency meets the goals and solves the task that are ultimately governed by the Directive and Appropriations instructions.

Principles and guidelines for statistics work

Statistics Sweden meets the UN Fundamental Principles for Official Statistics, and its operations are conducted in line with the International Statistical Institute’s (ISI) Declaration on Professional Ethics and the Swedish Statistical Association’s code of ethics for statisticians and statistical operations.

Statistics Sweden complies with the European Statistics Code of Practice, which is the cornerstone of the common quality framework of the European statistical system. The Code of Practice contains principles covering the institutional environment, statistical processes and statistical outputs.

How the quality is organised

Statistics Sweden’s managers are responsible for the quality work at each unit and department. The heads of each department are assisted by a quality coach, who works part-time to support managers and employees on quality issues. Statistics Sweden’s quality manager is in charge of evaluating the quality management system and coordinating the internal quality audits.

https://www.scb.se/en/About-us/main-activity/quality-work/

The quality of the Swedish Health Accounts can be considered high. For a smaller part of the Swedish Health Accounts model assumptions are being used,  for example occupational health care.

Main national users of SHA data in Sweden are:

-Swedish Association of Local Authorities and Regions (SALAR) wich is an organisation that represents and advocates for local government in Sweden. All of Sweden's municipalities, county councils and regions are members of SALAR.

-The National Board of Health and Welfare wich is a government agency under the Ministry of Health and Social Affairs, with a very wide range of activities and many different duties within the fields of social services, health and medical services, patient safety and epidemiology.

-The Ministry of Health and Social Affairs.

Statistics Sweden does not perform any user satisfaction surveys to determine user satisfaction.

Data are complete as far as the Commission regulation is applicable.

All of the for Sweden relevant data cells according to the regulation are complete. For some of the data cells outside the regulation data is missing. For example HF.3.1 Out-of-pocket excluding cost-sharing and HF.3.2 Cost-sharing with third-party payers are missing and instead reported under HF.3 Household out-of-pocket payment.

The Swedish Health Accounts are based almost exclusively on the National Accounts. In the National Account the largest proportion of the healthcare expenditure arise from the public sector which, in turn, are to a large extent examined through census. Therefore, the overall accuracy of the Swedish Health Accounts can be considered to be high.

For the compilation of the Swedish Health Accounts, surveys are not directly used.

Government consumption calculations are the main source of the Health Accounts. Since these are largely based on census, this source does not contribute to uncertainty.

Not applicable.

For the compilation of the Swedish Health Accounts, surveys are not directly used.

Not applicable.

Not applicable.

Item non-response may, however, occur, especially when individual respondents have not been able to specify the level of detail requested.
Overall, the non-response is considered to be very limited and does not significantly affect the reliability of the Swedish Health Accounts.

Not applicable.

Model assumptions are only used for a small part of the Swedish Health Accounts. It is prevalent in the area of occupational health care, health care in the correctional services and for private health insurance. The uncertainty due to model assumptions has not yet been quantified.

Not applicable.

General publication strategy or the National Accounts: In year t (2019): Preliminary estimates for year t-1 (2018) are published in February of year t (2019).
Revised preliminary estimates for year t-1 (2018) are published in November of year t (2019). Definitive estimates for year t-3 (2016) are published in September of year t-1 (2018).
Big scale revisions, in which Statistics Sweden applies all new insights, methods and sources are carried out approximately every 5 years. In 2015 this coincided with the provision of SHA 2011 figures. Sweden is planning to publish the next big scale revision in September of 2019.

The data for 2017 are to be considered as preliminary and will be revised next year due to definitive National Account data for 2017 that will then be available. According to the same approach the estimates for 2016 are now revised and is considered to be final. The total health expenditure for the year 2016 was revised by 298 MSEK. It was largely due to revisions in HF.1 Government schemes, -777 MSEK and in HF.3 Household OOP, 395 MSEK.

In 2019 JHAQ the total health expenditure for the year 2016 was revised by 298 MSEK. It was largely due to revisions in HF.1 Government schemes, -777 MSEK and in HF.3 Household OOP, 395 MSEK.

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. There is a voluntary deadline of 31st of March.

At an aggregated level the first result are published 3 months after the end of the reference year. At a more detailed level the results are published 15 months after the end of the reference year.

Final results at detailed level are published 27 months after the end of the reference year.

The data was delivered according to the voluntary deadline.

The data are delivered to Eurostat according to the voluntary deadline. At the same day as the transmission takes place national publications are published at www.scb.se/nr0109.

Not applicable at national level.

Not applicable.

Breaks in time series resulting from methodological changes

Both SHA and ESSPROS are compiled at Statistics Sweden, however SHA and ESSPROS are based on different underlying concepts as e.g. SHA is based on final consumption whereas ESSPROS is based on total expenditure. A full coherence between these different approaches are therefore not feasible. However, for some parts of SHA and ESSPROS where both are using the final consumption from the National Accounts coherence is achieved.

Not applicable.

The data is consistent between the core-tables.

The results are published annually at Statistics Sweden´s website, both as a "Statistical news" (text) and as tables in the statistical database.

https://www.scb.se/en/finding-statistics/statistics-by-subject-area/national-accounts/national-accounts/system-of-health-accounts-sha/

No publication is published.

The data is available in the statistical database at Statistics Sweden website, https://www.scb.se/en/finding-statistics/statistics-by-subject-area/national-accounts/national-accounts/system-of-health-accounts-sha/

Information not available.

Not applicable.

Data from the Swedish Health Accounts are used in several national publication. Examples of national publications are "Ett tandvårdssystem för jämlik tandhälsa" https://www.regeringen.se/493a2e/contentassets/143410af196646079e141bff42d428db/ett-tandvardssystem-for-jamlik-tandhalsa-dir-2018_16.pdf , "Öppna jämförelser 2017 En god vård?" https://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/20804/2018-1-4.pdf

Documentation regarding the Swedish Health Accounts are published annualy at www.scb.se/nr0109 (in Swedish) according to the quality policy of Statistics Sweden.

The quality report for the Swedish Health Accounts are published annualy at www.scb.se/nr0109 (in Swedish) according to the quality policy of Statistics Sweden.

Information not available.

Information not available.

Since the Swedish Health Accounts Data are based almost entirely on official National Accounts data the response burden for compiling this data is close to non-existent.

In terms of resources Statistics Sweden allocates approximately 560 hours per year to the production of the Swedish Health Accounts.

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

The Swedish Health Accounts are based on aggregated data, mainly from the National Accounts, or data without direct personal reference. Since only aggregated data or statistics without direct personal reference are used no additional confidentiality procedures are applied.

The Swedish Health Accounts data are based almost exclusively on the National Accounts.