System of Health Accounts (SHA 2011)

National Statistical Institute

"Health and Justice Statistics" Department

Evelin Yordanova

Head of department

2, P. Volov Str.; 1038 Sofia, Bulgaria

[email protected]

+359 2 9857 459

System of Health Accounts is being developed as a statistical system with repetitive current calculations and production of statistical information in accordance with a harmonized methodology and standard classifications. System of Health Accounts is an internationally accepted statistical system for description, classification and analysis of health care expenditure and sources of funding. The application of this statistical system aims to assess all health care expenditure - both public and household, spending of non-profit organizations - foundations, associations, private health insurance funds of enterprises for activities in labour medicine.

The main objectives of the System of Health Account are:

• to provide internationally comparable information in a system of standard matrices;
• to define harmonized health sector boundaries and to apply harmonized definitions;
• to distinguish the main functions of the health sector from the functions related to healthcare;
• to analyze the healthcare system from an economic point of view in accordance with the methodological principles of the macroeconomic (national) accounts and in accordance with the International Classification of Health Accounts.

SHA provides statistical information at national level on health expenditure by type of provider; by functions according to the aims of the medical activities (curative care, rehabilitation, clinical laboratory, sanitary transport, etc.) and according to the financial sources.

The definitions and classifications of the System of Health Accounts, Manual v.1.0. are followed for the period from 2010 to 2013, and for 2013 - 2021 data - the definitions and classifications of the System of Health Accaunts, ver. 2011. In addition, 2011 and 2012 data are elaborated according to the SHA, ver. 2011 requirements and following the requirements of "System of National Accounts, 2010" (SNA2010) and revisions done. 

During the process of 2018 data compilation, a revision was made in respect to the 2013 – 2017 data due to the inclusion of a new data source and the additional methodological work performed regarding the household expenditures estimation in order to improve the quality and comparability of the data.

During the process of 2019 data compilation, a revision was made in respect to the 2017 NHIF data. In accordance with the requirements of Commission Regulation 359/2015 and Eurostat methodological  guidelines the expenditure  in the revised tables are provided on an “accrual” principle,  i.е.  in the year when the activities were carried out, not when they were paid for.

Since 2020 - Expenditures on providing personal assistance for people with disability in accordance with the Personal Assistance Act (new legislation) are included. Expenditure on aids, devices, equipment and medical devices outside the scope of the compulsory health insurance, determined individually with a medical document issued by the medical advisory committees on the basis of their specific needs, regulated in the Persons with Disabilities Act  are included as well.

During the process of data compilation, since 2020 EU funds are also included, including those aiming to overcome the consequences of the Covid-19 pandemic.

Since 2021 - expenditure on the service "Assistant support" in accordance with the Social Services Act  as well as households’ expenditure for outpatient establishments for health care' expenditure (Medical-Treatment Facilities Act) are included. Expenditure on providing non-invasive rapid antigen tests to detect SARS-CoV-2 for students in schools which, according to the methodological requirements, fall within the scope of the study are also included.

The System of Health Accounts is built using the International Classification for Health Accounts by applying three specific classifications:

• Classification of Health Care Functions (ICHA-HC);
• Classification of Health Care Providers (ICHA-HP);
• Classification of Health Care Financing Sources (ICHA-HF) (SHA, ver.1.0);
• Classification of Health Care Financing Schemes (ICHA-HF) (SHA, ver. 2011).

Methodology and classifications have been developed by Eurostat, the Organisation for Economic Cooperation and Development and the World Health Organization.

All institutional and analytical statistical units that have functions according to the SHA classification of functions, regardless of whether they are in the statistical practice units of the Health sector as economic activities are included.

Data is compilated only on national level.

Health care boundaries

Determining the health care boundaries is supposed by the objectives of the SHA as a statistical system for representing the health expenditure of society as a whole and not just the healthcare system. The main criteria for defining the health care boundaries are as follow:

• defining the final use of health care goods and services according to the SHA classification of the functions;
• determining the boundaries between health and social care and
• classification of the healthcare expenditure by functions and providers.

The development of the SHA methodologically starts with the definition of the goods and services whose final consumption forms the Healthcare sector. According to the SHA methodology the total health expenditures measure the final use of these goods and services plus capital investments in institutions providing health services - those where healthcare is a predominant activity. The difference with the system of national accounts is that the health accounts include institutional and analytical statistical units that have functions according to the SHA classification of functions, regardless of whether they are in the statistical practice units of the Health sector as economic activities. All primary and secondary healthcare providers has to be included, regardless of whether they are classified by national statistics as statistical units of the Health sector.

System of Health Accounts is being developed in three subsystems. Subsystems are designed so that the aggregated tables are obtained by a detailed allocation of expenditure by function, by providers and allocation of functions by providers in separate tables.

The total expenditure is the sum of current and capital expenditure.

Total health expenditure includes both expenditure made by the public and private sectors.

The expenditure of the public sector includes general government, including public social security funds:

• Expenses of the state budget;
• Central government - ministries and institutions;
• Local government - municipalities;
• Social insurance funds - National Health Insurance Fund (NHIF) and the National Social Security Institute (NSSI).

According to the methodological requirements of the SHA, ver.1.0 the expenditure of the private sector include:

• Individual consumption expenditures of households on regulated payments for medical, dental and dental technical services, supplies, and other therapeutic goods. Also included are the payments in the system of retail trade in pharmacies, optical and sanitary shops.
• Claims paid by the voluntary health insurance companies;
• Expenditures of non-profit institutions serving households - as these expenses can not be allocated in detail by functions and  by providers, they are allocated to non-classified activities.
• Expenditure of enterprises and organizations for activities related to labour health care for employees.

According to the methodological requirements of the SHA, ver. 2011 expenditures for Voluntary health care insurance and enterprises' and organisations' expenditures for labour medical activities are separated from private sector in a separate Voluntary Health Care Payment Schemes.

Classification of healthcare providers (ICHA-HP)

Classification of healthcare providers aims reclassification of national institutions in the health sector in internationally comparable and relevant categories of providers of health services. Classification of providers of health care services includes units in which the production of health services is a major activity and those in which the production of health care is a secondary activity. As providers of health services in SHA are also classified the households in the case of care for a sick family member and care of nursing type.

Classification of Health Care Functions (ICHA-HC) essentially contains two classification attributes:

1. Main purpose/type of medical care or activity:

• Curative care;
• Rehabilitation;
• Ancillary  services;
• Medical goods for patients in outpatient care;
• Prevention and public health;
• Administrative costs for health administration and administration of health insurance.

2. Mode of provision

• Inpatient care;
• Outpatient care;
• Day care;
• Home based care.

Through this classification the expenditures on personal and collective healthcare goods and services are analysed. Health care combines (includes) personal health services provided directly to the individual and collective health services which relate to the implementation of tasks of public health such as prevention, prophylactic, health administration and health insurance administration.

Commission Regulation 2021/1901 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".
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.
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 2021/1901 limits its scope to the collection of data on the expenditure of health care financing schemes.

All institutional and analytical statistical units that have functions according to the SHA classification of functions, regardless of whether they are in the statistical practice units of the Health sector as economic activities are included.

Territory of the Republic of Bulgaria.

2010 - 2013 (data according to the SHA, ver.1.0);
2011 - 2021 (data according to the SHA, ver. 2011).

Not applicable.

Million BGN.

Year

Regulation (EC) No 1338/2008 of the European Parliament and of Council of 16 December 2008 on Community statistics on public health and health and safety at work.
Commission Regulation (EU) 2021/1901 implementing Regulation (EC) N 1338/2008 of the European Parliament and Council as regards statistics on healthcare expenditures and financing.

In accordance with the basic principles and strategy for international cooperation in the field of health statistics, in December 2006 the Organization for Economic Cooperation and Development, the World Health Organisation and Eurostat launched a joint collection of information according the system of health accounts through a standardized questionnaire.
Since 2014 data are provided to all three institutions in line with the Regulation (EU) 2015/359.

Since 2021 data are provided to all three institutions in line with the Regulation (EU) 2021/1901.

• Law on Statistics;
• Regulation (EC) No 223/2009 on European statistics (recital 24 and Article 20(4)) of 11 March 2009 (OJ L 87, p. 164), stipulates the need to establish common principles and guidelines ensuring the confidentiality of data used for the production of European statistics and the access to those confidential data with due account for technical developments and the requirements of users in a democratic society.

Individual data are not published in accordance with article 25 of the Law on Statistics. The publishing of individual data can be performed only in accordance with article 26 of the same law.

The date of the statistical information release is shown in the Release Calendar presenting the results of the statistical surveys carried out by the National Statistical Institute.

Statistical information by system of health accounts is published annually: 22 months after the expiration of the relevant reference period and after completion of the procedure on data validation by the international team of experts from Eurostat, OECD and WHO.

The calendar is available on the NSI website: https://www.nsi.bg/en/node/480.

Data on System for health accounts are published on the website of NSI, section Health in accordance with the Law on Statistics (Chapter 5) and the European Statistics Code of Practice, respecting professional independence and aiming objectivity and transparency, in which all users are treated fairly.

Annually

Not applicable.

Not applicable.

Detailed data on the system of health accounts are available to all users on the NSI website under the heading Health - System of Health Accounts: https://www.nsi.bg/en/node/5568.

Online on Eurostat database.

Not available.

Information service on request, according to the Rules for the dissemination of statistical products and services in NSI.

• System of Health Accounts - Organization for Economic Cooperation and Development, 2000 - ver. 1.0;
• Eurostat methodological guidelines for the Joint OECD, EUROSTAT and WHO Health Accounts (SHA 2011) Data collection;
• System of Health Accounts, OECD Publishing (SHA 2011) - OECD, Eurostat, WHO - ver. 2011.

Quality report.

The National Statistical Institute as an authoritie responsible for SHA data collection is 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.

Integrated quality and security management system has been implemented in accordance with the requirements of BDS EN ISO 9001: 2015 and BDS EN ISO 27001: 2017. The certificate fully meets all international requirements and guarantees the quality of the processes and information security of the entire statistical and information infrastructure of the NSI, both at national and regional levels.

The quality of the data is subject to the way, in which health care provision is organised in countrie, and which information is available to and collected by the respective institutions.

The National Statistical Institute is continuously working to maintain and improve the quality and the comparability of SHA data.

Health accounts are increasingly expected to provide inputs (along with other statistical information) into improved analytical tools to monitor and assess health system performance. One high priority is to develop reliable, timely data that is comparable both across countries and over time. This is indispensable for tracking trends in health spending and the factors driving it, which can in turn be used to compare it across countries and to project how it will grow in the future.

Health accounts are thus used in two main ways: internationally, where the emphasis is on a selection of internationally comparable expenditure data, and nationally, with more detailed analyses of health care spending and a greater emphasis on comparisons over time. Health accounts are crucial for both of these.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

The data are provided to Eurostat, WHO and OECD in accordance with the deadline set out in Commission Regulation 2021/1901. Once the validation process has been successfully completed, the data is published - T + 20 months

Data are disseminated according to the Release Calendar presenting the results of the statistical surveys carried out by the National Statistical Institute - usually T+22 or once the validation process has been successfully completed.

Not applicable.

2010 - 2013 - data according to the SHA, ver.1.0;

2011 - 2021 - data according to the SHA, ver. 2011. 

Since 2013, there is a break in time series. The data are comparable for the period 2013 – 2021.

Not applicable.

The data are reconciled. Aggregate tables are obtained by a detailed allocation of expenses by function, by providers and about functions by providers in separate tables.

Not applicable.

Where a new source of information is identified and used, the data for previous years shall be revised if possible.

2011 and 2012 data are revised according to the System of Health Accaunts, ver. 2011 requirements. In addition, 2011 and 2012 data are elaborated following the requirements of "System of National Accounts, 2008" (SNA2008) and revisions done.

During the process of 2018 data compilation, a revision was made in respect to the 2013 – 2017 data due to the inclusion of a new data source and the additional methodological work performed regarding the household expenditures estimation in order to improve the quality and comparability of the data.

During the process of 2019 data compilation, a revision was made in respect to the 2017 NHIF data. In accordance with the requirements of Commission Regulation 359/2015 and Eurostat methodological guidelines the expenditure in the revised tables are provided on an “accrual” principle,  i.е.  in the year when the activities were carried out, not when they were paid for.

• Ministry of Finance – Report on the State Budget Execution of the Republic of Bulgaria, Statement of the Cash Execution of the Budget and detailed information on the Function “Health” expenditures by paragraphs and sub-paragraphs of the Budgetary Classification; Decree of the Council of Ministers on the activities delegated by the state and financed by the munisipality budgets - as regard the expenditure on the service "Assistant support". As regards COVID-19 related costs, additional reports are used as data source for 2020 and 2021 - Report on measures to prevent the spread of COVID-19 and its treatment, business support measures and social measures (other ministries data except the Ministry of Health); Report on expenditures and sources of their funding in connecton to the measures to prevent the spread of COVID-19 - concerning expenditures payed by the munisipalities.

• National Health Insurance Fund - Report on NHIF budget execution; in addition detailed administrative information on the expenses of the NHIF according to the SHA methodology is provided;
• Ministry of Health - Report on MH budget execution; in addition detailed administrative information on the expenses of the MH according to the SHA methodology is provided;
• National Social Security Institute – „State Social Security“;
• Social Assistance Agency at the Ministry of labor and social policy – detailed administrative information on the expenses of the SAA according to the SHA methodology is provided;
• Generally the National Accounts estimation on household’s individual consumption of health services is taken into account and a cross-validation between results obtained from NSI annual business statistical surveys and national accounts estimate is done. Disaggregation and reclassification of expenditure by providers and functions is done by combined using of data from statistical surveys in the field of business and health statistics as well as Household Budget Survey;
• National accounts - final consumption expenditure of non-profit institutions serving households for Health;
• Business statistical surveys:

1. Accountancy and statistical reports of Private health inshurance funds, by 'medical packages';
2. “Annual report of non-trade enterprises” - accountancy and statistical reports of Health establishments applying double-entry accounting as well as those applying single-entry accounting (that do not prepare balance);
3. Survey on domestic trade - Retale sales by group of goods.

Since 2021 National Center for Public Health and Analyses at the Ministry of Health statistical data on the immunizations and reimmunizations carried out in medical and health care facilities are used to estimate the expenditures of households for voluntary vaccinations.

Annually

Exhaustive for all units.

In order to ensure consistency and completeness of the results, the data is validated at national level as follows:

• evaluation of completeness and coverage of each data source;
• analysis of trends, growth rates and anomalies;
• cross-validation between different data sources.

At the next stage data is validated by a team of experts from the three organizations - Eurostat, WHO and OECD.

Data validation is performed  as follow:

1. Consistency of the data between tables;
2. Consistency of the data within tables, including a presence of negative values or atypical entries;
3. The growth rates against the previous year.

Construction of the System of health accounts is done by usage of “bottom-up” approach, i.e. working with primary data by making a compilation, balance sheet according the three classifications.

Rules of arithmetic and logical sequence hitch between the three subsystems are applied.

Household expenditures estimation

Business statistical surveys (annual records on accountancy and statistical reports) conducted by NSI are the basic data source:

All enterprises in the country that submit “Annual report of non-trade enterprises” and are classified in 86, 87 and 32.50 according to the Classification of Economic Activities (NACE.BG-2008) are exhaustively covered.

Units are reclassified in specially developed tables in accordance with the Classification of healthcare providers (ICHA-HP). For assessment of the coverage of the units as well as the correct classification of providers according to the methodological requirements of the SHA, information from the NSI exhaustive survey "Inpatient and outpatient health establishments and other health establishments" is used. For establishments outside the business statistical surveys coverage, information is based on expert estimation.

Data are proceeded case by case in order to classify the revenue from population data in accordance to the Classification of Health Care Functions (ICHA-HC).

Generally the National Accounts estimation on household’s individual consumption of health services as well as HBS data on household expenditure are taken into account and a cross-validation between results obtained from NSI statistical surveys is done.

Concerning HC5 Medical goods estimation - Estimations are done based on retail sales by group of goods for the group "Pharmaceuticals, medical and orthopaedic goods" according to the Classification COICOP and NACE code of the enterprises. NACE codes that are covered: 21, 26, 46, 47.1, 47.2, 47.73, 47.74, 47.78. The estimation is based on the methodological requirements of the SHA 2011 Manual.

Since 2020 - Register of persons performing activities for the provision of medical devices and aids, devices and equipment for people with disabilities is used in order to verify the  expenditures estimation for  medical devices (HC5.2) payed by the households (HF3).

Since 2021 - National Center for Public Health and Analyzes at the Ministry of Health exhaustive annual survey on the immunizations and reimmunizations carried out in the medical and health facilities is used in order to verify and balanced the HC5.1 expenditure payed by HF3. 

Household expenditures information broken down by providers and by function should be balanced.

Covid-19 current expenditures estimation

Since 2020, in accordance with the System of Health Accounts’ methodological requirements  in order comparability of statistical information at the EU level to be enshured, the following public expenditures, including EU funds (HF1), related to prevent the spread of COVID-19  has been included:

• for the period of the declared emergency epidemic situation, in accordance with the national legislation, the NHIF has introduced payment for work under unfavourable conditions due to the declared epidemic situation, as the right to this payment have all providers of medical and dental care who have a contract with the NHIF and have fulfilled relevant criteria (providers of primary and specialized outpatient care; dental care providers; hospital medical care; providers of laboratory activity);
• expenditures on support the staff of the "first line" directly involved in the activities to prevent the spread of COVID-19 (including EU funds) - allocated by the relevant providers of health services;
• subsidies for the medical establishments for hospital care, incl. to maintain readiness for medical care during the period of declared epidemic emergency and for additional remuneration of the medical personal (allocated in НС1, curative care);
• provided funds (including EU funds) for medical and non-medical persons directly involved in the fight against and prevention of the spread of COVID-19 – Centres for emergency health care (HP41xHC43), National Centre of Infectious and Parasitic Diseases etc;
• expenditures on increase the remuneration of administrative staff to the Minister of Health, who are in charge of pandemic activities and the consequences of COVID-19, whose duties include ‘field service and control’ with direct contact with other persons (HP7xHC7 in respect to the administration; HP7xHC65 concerning activities related to the tracing the contacts of infected cases, HP6xHC65 – activities related with the risk analysis and epidemiological operative investigation; daily updates of data etc.);
• expenditures on additional remuneration for health mediators carried out active work on the first line in the conditions of a developing pandemic of COVID-19 to the affected population in the municipalities – HF11xHP6xHC61;
• NHIF payments for laboratory tests and Imaging services (HC41 and HC42);
• expenditures on personal protective equipment (masks, gloves, etc.) for the needs of the state administration, as well as for disinfectants, disinfection of work premises, thermometers for remote measurement, etc., which according to the SHA requirements has been considered as occupational medicine costs (HP82 x HC513);
• costs for protective equipment (masks, gloves, etc.), disinfectants (personal and for the premises) in schools,  which according to the SHA requirements has been considered as expenditures on pre-school and school child health (HP82 x HC513);
• COVID-19 related costs for pre-school and school child health (HP82xHC64);
• expenditure on providing non-invasive rapid antigen tests to detect SARS-CoV-2 for students in schools (НР82xHC63).

Expenditures on testing for patients with and withut symptoms in hospital establishments could not be separated and are included in HC1.

Expenditures on personal protective equipment (masks, gloves, protective clothing, protective glasses) for the medical establishments, as well as disinfectants (personal and for the premises), consumables, reagents, medicines, PCR tests, antigen tests, etc.) are allocated to curative care (НС1).

Expenditure on purchasing COVID-19 vaccines are not included. MH and NHIF expenditure on the activities of the COVID-19 vaccines placement are included.

According to the SHA requirements expenditure of purchasing the types and quantities of state reserves necessary to overcome the consequences of a crisis situation are not included.

Household’s COVID-19 related expenditures cannot be separated from the overall estimate of household expenditure.

Not applicable.