Statistical Office of the Republic of Slovenia - SORS.

Demography and Social Statistics Division
Demography Statistics and Level of Living Section

Litostrojska cesta 54, SI-1000 LJUBLJANA
Phone: +386 1241 5 225

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.

Detailed data is available from 2003-2016 for Slovenia. Main aggregates are also available for 2017.

Not applicable.

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

-          Surveys/census: 0

-          Public administrative records: 2

-          Financial reports: 7

-          Other: 3

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.

Annual accounts of central and local governments are submitted annualy to NSI (mainly for the purpose of National Accounts compilation).

Data for social health insurance is transmitted in an Excel form (very detailed) and is further processed and coded (also SHA-coded) by NSI Slovenia.

Results from National Accounts are obtained from NSI colleagues, while the same person is in charge for both SHA and ESSPROS statistics.

Some reports concerning Pension and Disability Insurance Institute of Slovenia and Social Protection Institute of the Republic of Slovenia are published on their website and taken from there.

Additional data/reports/information from some ministries, especially Ministry of Labour, Family, Social Affairs and Equal Opportunities and some other institutions are submitted after request.

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.

Checks are carried out for completeness, internal and external consistency and plausibility of the collected internal and external data. Additional measures undertaken to guarantee high quality of SHA data compilation are also regular discussion of results and methods with main users of SHA data.

The quality of SHA figures can be considered to be quite good. Areas where data is not fully in line with SHA guidelines or are partially missing are outlined under 5.3 and 6.3.1.

Main users of SHA data are Ministry for Health, Ministry for Labour, Family, Social Affairs and Equal Opportunities, Health Insurance Institute of Slovenia, National Institut for Public Health, as well as Institute of Macroeconomic Analysis and Development and Institute for Economic Research for policy making and policy evaluation process. Most of these institutions also take part in a data compilation process each year and on further improvement of data sources.

SHA data is recently mostly used for the need of preparing some strategic documents and legislation on long-term care.

Media, education institutions like universities, other research institutions, students and the general public also are requesting SHA data on ad-hoc basis.

As concerns unmet needs, one of these is health care expenditure by patient characteristics, which allows monitoring of expenditure by groups of diseases and age and sex of the patient and are therefore important both for long-term growth projections of health care expenditure as well as planning staff in health care (including by specialty).

User satisfaction is analysed on yearly basis when discussing main results and methods of SHA with some main users of data, especially with Health Insurance Institute of Slovenia and Institute of Macroeconomic Analysis and Development. Several contacts are also made during the year when necessary.

Overall, data are complete as far as the Commission Regulation is applicable (for exceptions see 6.3.1.)

Almost 100 % for mandatory variables of the three dimensions according to Commision Regulation that are relevant/occuring in the Slovenia health system (for exceptions see 6.3.1.)

As the SHA tables are the result of an integrated various data sources as well of estimation, the figures can not be 100 % accurate. Nevertheless, overall accuracy can be considered to quite good, with some known under-coverages, which are explained under 6.3.1.

Not applicable, since no surveys are used as a data source.

Not applicable.

Coverage error explained under 6.3.1.

Curative and rehabilitative care HC.1. and HC.2.

Input data from Health Insurance Institute of Slovenia - HIIS (social health insurance) prepared for the needs of health accounts are detailed broked down by health care providers and health care functions, therefore there is no deviations regarding the HP classification and no major deviations according to the HC classification. According to data received from HIIS is not possible to exclude expenditure on laboratory services for outpatient patients (HC.4.1.), therefore these expenditure is included in various items of outpatient treatments. Furthermore, from HIIS database we could not obtain information about all daily hospital treatment HC1.2, only dialysis were recorded separately; nevertheless this segment is later in data processing adjusted -  from total expenditure of HC.1.1 (HP.1.1) according to additional information on share provided by HIIS of Slovenia - daily cases are deducted and added to HC.1.2.

Ancillary services HC.4.

(HC.4.2) Expenditure on imaging services  for Roentgen and ultrasound services derivated from HIIS database includes this services only for outpatient patients, which is in line with SHA; while expenditure on magnetic resonance imaging - MRI and computed tomography - CT is recorded for both, inpatient and outpatient (it can not be separed according to obtained HIIIS database).

NPISH financing shemes (HF.2.2)

Non-profit providers of office services due to problems in data sources have not yet been fully covered, with the exception of one major institution.

Enterprise financing schemes (HF.2.3)

This item only includes “occupational health examinations”: estimated expenditure for preventive care,  data on number of preventive examination for  employees multiplied by expert assessment of the average price of one examination.

Cost-sharing with third-party payers (HF.3.2.)

Missing (data not available).

Out of pocket payments (OOP); informal payments

Informal payments are adequately covered in health accounts because estimation of OOP is taken from national accounts statistics (where HBS survey for OOP is taken into account and HBS survey cover also informal household expenditure); only informal payments for long-term health care HC.3. are underestimated (in this HC there is also the largest share of informal payments in Slovenia).

Not applicable.

Not applicable.

Errors in reading, calculating or recording numerical values may appear, but they are usualy recognised at the end of data processing or through validation process (as an outliers).

Not applicable.

Not applicable.

Not applicable.

Typing errors (data entry and data coding) and errors due to misinterpretation (data coding) may appear, but they are usualy recognised at the end of data processing or through validation process. Analysis of processing errors is not carried out on a yearly basis.

Not applicable.

Not applicable.

Not applicable.

Published data on health expenditure and sources of funding in Slovenia have no provisional nor final status of data, since they are subject of regular annual revision either because of changes in the input data themselves, either because of the methodology itself, which is always improving.

We revised data according to revisions of data which present input for SHA data - in general, the most revised is OOP category or expenditure.

Revisions are usually made also because of change of methodology (definition of certain category) - for example, more detailed definition of LTC category, split between health and social component of LTC category.

In general, with each data submission in the year t-2 during the validation process one or two previous data are revised. Usually, the data validation process results in reclassification of figures between the categories on the second digit level within one HC or HP, but as we are currently publishing data at more aggregate levels, revisions actually are not detected in the published data.

A major revision for 2010 – 2015 was in 2018, namely due to a one-time transfer from the state budget in 2017 to cover the losses of hospitals from previous years.

The magnitude of major revision for 2010-2015 amounted to 0.2% - 1.3% of current health care expenditure.

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.

Published data on health expenditure and sources of funding in Slovenia have no provisional nor final status of data. Data for year T-2 are published in July of year T.

Published data on health expenditure and sources of funding in Slovenia have no provisional nor final status of data. Data for year T-2 are published in July of year T.

There were no major deviations from deadlines in the reference period.

Data for reference year 2014 was transmitted on 1st July 2016 (deadline was: 31 May 2016).

Data for reference year 2015 was transmitted on 12 May 2017 (deadline was: 30 April 2017).

Data for reference year 2016 was transmitted on 26 April 2018 (deadline was: 30 April 2018).

Not applicable at national level.

Not applicable.

Data according to SHA 2011 is available from reference year 2014  to 2016 and is comparable over this time. Data according to previous SHA 1.0. (2000)  methodology is available from 2003 – 2013. Break in time series was made with introduction of SHA 2011 methodology.

Breaks in time series resulting from methodological changes

Three years (2014-2016) for SHA 2011 data and ten years for SHA 1.0 data.

The SHA figure can be partly reconciled with ESSPROS statistics (inside Sickness/Health care function, Disability and Old age function and Social exclusion n.e.c, considering different health care boundaries between methodologies.

Agregate from ESSPROS: In-kind social protection expenditures on Sickness/Health care covers in-kind benefits related to direct provision and reimbursement of health care goods an services although due to different healt care boundary, the scope of health care goods and services in ESSPROS is limited as compared to SHA 2011 (SHA includes expenditure related to collective preventive programme, long-term (health) servises provided at home by familiy members, the latter being recorded under Sickness/helath care benefit in cash. Other ESSPROS functions may comprise expenditure that is included as health care goods and serices in SHA 2011 as it can be seen from table below.

            ESSPROS                    –                        SHA linkage (HC functions)

The SHA figure can be partly reconciled with ESSPROS statistics also due to the fact that same person compiles ESSPROSS and SHA statistics.

Not applicable.

When compiling the health accounts, we compare the main aggregates SHA with national accounts, specially coherence with following aggregates (taking into account some limits in boundaries of health care):

- total SHA current health expenditure with final health consumption from SNA, 

- current SHA public health expenditure with final SNA government consumption on health care,

- current SHA private health expenditure with final SNA consumption for health care of households.

In addition to consumption side, we are also checking indicative alignment with SNA aggregates on production side. Methodological derogations between SHA and SNA on production side are quite large; according to SNA the aggregate of production includes all production of operators registered in healthcare activities (group code 86 of NACE), therefore also the production of non-health products, health products and services for intermediate consumption and production of health services for foreigners, which is not the case of SHA.  On the other hand, some health activities, for example, pharmacy activity and management of the health system (administration), are included in other NACE activity codes, but the latter can be taken into account in comparison of aggregates of SHA and SNA.

For public health expenditure on health, we also check the indicative compliance with the general government expenditure per purposes (classification of COFOG) for the field 07-Health, at the aggregate level and at the second level of the COFOG classification. We take into account the cross-code between the classification of health care purposes (HC),  the classification of general government purposes (COFOG) and methodological differences between SHA and COFOG methodology.

Internal coherence of SHA tables is achieved. For consistency checks and validation methods see 3.4.

A news release on health care expenditure and sources of funding is published every year at the end of July for the year t-2.

Some SHA data are published in SORS yearly publication: Statistical Overview of Slovenia 2018.

We are currently not using an online database for SHA dissemination, instead of this, SHA data is published in Excel files (main agregates from three cross-classification). Data can also be obtained from the health databases of OECD, EUROSTAT and WHO.

Currently SORS is not using an online database for SHA dissemination, therefore it is not possible to analyse the number of views in database.

But SORS has analysed the number of unique views on news releases: from June 2017 to June 2018, 664 unique page views have been performed for SHA news releases.

Not applicable.

Other major publications using/containing SHA data are e.g.:

- OECD: Health at Glance,

- National Institute of Public Health of Slovenia: Statistical health care yearbook.

The metadata are published on SORS website (https://www.stat.si/StatWeb/File/DocSysFile/8315).

Not available.

Not available.

Not available.

Costs for production of statistical data and burden or respondents is not measured, due to the fact that this is mostly on data providers side. Preparing data for SHA needs from side of data providers is very diverse, some data providers needs 5 minutes, others 1 hour, etc. No additional analysis were carried out due to diversity.

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

On national level, National statistics act, applies (Articles 40 - 51).

SHA data is published at relatively high aggregated data level, detailed data is not published or distributed. When users are making requests at more detailed level, rules written in National statistics act regarding confidentiality are strictly followed.

No additional comments.