Draft Guidelines for the SHA

2011 Framework for Accounting

Health Care Financing

13th Meeting of Health Accounts Experts, OECD, Paris 4-5 October 2011

Eva Orosz, head of Health Policy and Health Economics Department, ELTE University, Faculty of Social Sciences, Budapest

Overview

• Purposes of the Financing Guidelines

• Preparation of the Guidelines: a collaborative effort

• The structure and some key issues

• Further steps

• Issues for discussion

The Interim Report presents

• a framework of the SHA 2011 Financing Guidelines;

• a draft of their main elements; and

• proposals for further work.

Financing Guidelines intend to provide

• a more detailed explanation of the changes in concepts related to health care financing in SHA 2011;

• general approaches for the preparation of SHA tables relevant to health care financing; and

• possible tools (e.g., working tables) useful in the case of complex financing arrangements.

Development of Financing Guidelines is a

collaborative effort

• The Interim Report will be discussed by

– a peer review group;

– participants of the 2011 OECD Meeting of Health Accounts Experts;

– countries already pilot tested SHA 2011.

• The Financing Guidelines (selected elements) are to be tested.

• New elements can be added in a step-wise

approach.

How to use the SHA Financing Guidelines

• Financing Guidelines complement the relevant chapters

of the SHA 2011 Manual.

• On the other hand, the guidelines are a stand-alone document.

• It is not expected that countries will implement all elements of the Financing Guidelines. Factors influencing a country’s choice among the various tools

are:

– differences in the complexity of health financing systems,

– health policy issues of interest,

– data availability and available resources.

Structure of the Financing Guidelines

1. The overview of the accounting of health care financing under SHA 2011

2. Description of the health care financing system from a health accounting point of view

3. Accounting the government’s involvement in the health sector

4. The interpretation of “public” and “private” under SHA 2011

5. Accounting foreign aid

6. Transition from SHA 1.0 to SHA 2011 – regarding the classifications of health care financing

7. Preparation of SHA 2011-based health accounts tables relevant to health care financing

8. Accounting health care financing from the perspective of the individual schemes and institutional units

Key issues of the Guidelines

From a health policy perspective

• Information on health financing functions and performance of the financing system – Role of the government

– Role of foreign aid

• Information on changes in institutional arrangements of health care finance

• Interpretation of „public” and „private”

From a health accounting perspective

• Identification and relationships between

– providers of financial resources

– financing schemes

– financing agents

• Accounting of the basic flows: (i) revenue-raising by the financing schemes; and (ii) allocation of resources

• Transition from SHA 1.0 to SHA 2011

• Accounting health financing from the perspective of the individual schemes and institutional units

HOUSEHOLDS

EMPLOYERS

ROW

NGO

GOVERNMENT

CENTRAL GOV

SCHEMES

STATE/LOCAL

GOV SCHEMES

COMPULSORY

HEALTH

INSURANCE

VOLUNTARY

HEALTH

INSURANCE

HOUSEHOLD OOP

NPISH FINANCING

SCHEME

ENTERPRISES

FINANCING

SCHEMES

ROW FINANCING

SCHEMES

MINISTRY OF HEALTH

OTHER MINISTRIES

NGOs

LOCAL GOV

NGOs

HEALTH INSURANCE FUNDS

OTHER SOCIAL INSURANCE FUNDS

INSURANCE COMPANIES

HEALTH INSURANCE FUNDS

INSURANCE COMPANIES

HOUSEHOLDS

HOUSEHOLDS

NGOs

HOUSEHOLDS

ENTERPRISES (1)

ENTERPRISES (2)

GOV UNIT

FOREIGN NGOs

LOCAL NGOs

PR

OV

IDE

RS

All lines represent financial or in-kind resource flow

The overview of the accounting of health care financing

under SHA 2011

Description of the health care financing system

from a health accounting point of view

• Identification of the health financing schemes

• Description of the functional and institutional structure of the health financing system (HF and FAs)

• Identification of the basic flows:

– (i) revenue-raising

– (ii) allocation of resources

• Identifying problem cases

• Clarifying the most important differences between classifications of health financing of COUNTRY (A) under SHA1.0 and SHA 2011

ICHA-HF Health financing

schemes in

COUNTRY(A)

Participation and

benefit entitlement

Benefit

package

Statutory social health

insurance

Other health-related

insurance schemes

(operated by the

retirement funds)

HF.

1.2.1

Social health insurance

schemes

Statutory long-term

care insurance scheme

*

LTC

Compulsory private

health insurance

schemes

Individuals with an

income above a

threshold can opt

out of the SHI

HF.

1.2.2

Compulsory private

insurance schemes Statutory long-term

care insurance scheme

*

LTC

Identification of the health financing schemes in

COUNTRY(A) (Table 2.1)

ICHA

-HF

Health financing

schemes in

COUNTRY(A)

Main financing

agents in

COUNTRY(A)

FA

code

SHA2011

Financing

Agent

DATA

SOUR

CES

Data

problems

HF.1.1

Governmental

schemes

HF.

1.1.1

Central

governmental

schemes

FA.

1.1 Central

government

Ministry of

Health (P)*

FA.

1.1.1 Ministry of

Health

Special scheme for

the army

Ministry of

Defence (P)

FA.

1.1.2 Other

Ministries and

public units

Special scheme for

the police

Ministry of

Interior (P)

FA

1.1.2 Other

Ministries and

public units

National Tax

Authority (C)*

A national cancer

prevention

programme

NPISH(a) (C)

FA.4 NPISHs

HF.

1.1.2

State/ regional /

local governmental

schemes

State

governments

(C&P)

FA.1.2 State/ regional

/ local

government

Description of the functional and institutional structure of

the health financing system (Table 2.4)

FS

.1

FS

.1.1

FS

.1.2

FS

.1.3

. FS

.1.

4

FS

.2

FS

.3

FS

.3.1

FS

.3.2

FS

.3.3

FS

.3.4

FS

.4

FS

.4.1

. FS

.4.2

. FS

.4.3

. FS

.5

FS

.5

FS

.6

FS

.6

FS

.7

Go

ver

nm

ent

do

mes

tic

rev

enu

es

Inte

rnal

tra

nsf

ers

and

Gra

nts

Tra

nsf

ers

on

beh

alf

of

spec

ific

gro

up

s S

ub

sid

ies

Oth

er t

ran

sfer

s fr

om

gov

ernm

ent

do

mes

tic

rev

enu

es

Tra

nsf

ers

by

go

ver

nm

ent

fro

m

fore

ign

ori

gin

S

oci

al

in

sura

nce

co

ntr

ibu

tio

ns

Em

plo

yee

so

cial

in

sura

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con

trib

uti

on

E

mp

loy

er

soci

al i

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ce

con

trib

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Sel

f-em

plo

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cial

in

sura

nce

con

trib

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on

Oth

er s

oci

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nsu

ran

ce c

on

trib

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on

Co

mp

uls

ory

p

rep

ay

men

t (o

ther

tha

n F

S.3

)

Co

mp

uls

ory

pre

pay

men

t fr

om

ho

use

ho

lds

Co

mp

uls

ory

pre

pay

men

t fr

om

emp

loy

ers

Oth

er C

om

pu

lso

ry p

rep

aym

ent

Vo

lun

tary

p

rep

ay

men

t

Vo

lun

tary

p

rep

aym

ent

fro

m

ho

use

ho

lds

Vo

lun

tary

p

rep

aym

ent

fro

m

emp

loy

ers

Oth

er V

olu

nta

ry

pre

pay

men

t

Oth

er

do

mes

tic

rev

enu

es n

.e.c

.

Oth

er

rev

enu

es f

rom

ho

use

ho

lds

n.e

.c.

Oth

er

rev

enu

es f

rom

co

rpo

rati

on

s

Oth

er

rev

enu

es f

rom

NP

ISH

s n

.e.c

.

Dir

ect

Fo

reig

n t

ran

sfer

s

All

rev

enu

es o

f fi

na

nci

ng

sch

ema

To

tal

cu

rren

t ex

pen

dit

ure

an

d

cap

ita

l tr

an

sfer

s b

y f

ina

nci

ng

sch

emes

Op

era

tin

g b

ala

nce

HF.1 Governmental schemes

and compulsory private

schemes

x

HF.1.1 Governmental schemes x x x x x

HF.1.2.

1

Social health insurance

x x x x

x x x x

x

HF.1.2.

2

Compulsory private health

insurance

x x x x x

HF.2 Voluntary health care

payment schemes

x

HF.2.1 Voluntary insurance x x x x x x x

HF.2.2 NPISH financing schemes x x x x x x x

HF.2.3 Enterprises financing

schemes

x x

HF.3 Households out-of-

pocket payment

x x

HF.4 Rest of the world

financing schemes

x x

Identification of the basic flows: revenue-raising (Table 2.5)

Functions of the government

Accounting categories

Accounting tools (tables)

Regulation Governmental schemes (HF)

HC.7xHF.1.1 HP.7.1xHF.1.1

Revenue-raising Provider of revenues

FS.1xHF.1.1 FS.1xHF.1.2 FS.1xHF.2

Financing agent collecting revenues

HF.1.1xFA.1 xHC.7

Pooling Financing agent pooling revenues

HF.1.1xFA.1 xHC.7

Purchasing Financing agent paying for services

HF.1.1xHC HF.1.1xHP

Provision of services Owner of providers

Accounting the government’s involvement in the

health sector

Accounting the government’s involvement in

the health sector (2)

• Transactions by governmental financing schemes (HF.1.1)

• Transactions related to government health-related functions (HCR.1, HCR.2)

• Transactions related to resource-generation (human and physical capital and technology)

• Providing revenues by the government to HF.1.1. and other financing schemes (FS.1, FS.2)

• Transactions made as an intermediary institution (e.g., between foreign NGO and local NGOs)

• Non-health spending by the government units acting as financing agent

Interpretation of “public” and “private” under SHA 2011

Revenues from

compulsory

payment

Revenues from

voluntary payment

HF.1. Governmental

and compulsory

contributory schemes

HF.2. Voluntary

health care

payment

schemes

Public financing

agents (FA)

Private

financing

agents (FA)

Public providers Private providers

HF.1 managed by

public FA

HF.1 managed

by private FA

HF.2

managed by

public FA

HF.2

managed by

private FA

17

Financing schemes Major expenditure aggregates

HF.1 Governmental financing schemes and compulsory contributory health financing schemes

Expenditure by government schemes and compulsory contributory health financing schemes (instead of „public expenditure”)

HF.1.1 Governmental financing schemes

HF.1.2.1

Social health insurance

HF.1.2.2

Compulsory private health insurance

HF.1.3 Compulsory Medical Saving Accounts (CMSA)

HF.2 Voluntary health care payment schemes (other than OOP)

Expenditure by voluntary health financing schemes (instead of „private” expenditure)

HF.2.1 Voluntary health insurance

HF.2.2

NPISHs-financing schemes

HF.2.3

Enterprises financing schemes

HF.3 Households out-of-pocket payment

HF.4 Rest of the World financing

programmes

Expenditure by RoW schemes

Refinement of the categories of „public” and „private” (1)

Would

have

been

categori

zed as

private

under

SHA1.0

18

Revenue of financing schemes

Major expenditure aggregates

FS.1

Transfers from government domestic revenue

Public and compulsory private funds spent on health care

FS.1.1 Internal transfers and grants

FS.1.2

Transfers by government on behalf of specific groups

FS.1.3 FS.1.4

Subsidies; Other transfers from government domestic revenue

FS.3 Social insurance contributions

FS.4

Compulsory prepayment (other than FS.2)

FS.2; FS.7.1.1; 7.1.2; 7.2.1.;

Bilateral and Multilateral financial transfers and aid in kind

FS 5. Voluntary prepayment Voluntary private funds spent on health care

FS 6 Other domestic revenues n.e.c

FS.7.1.3; FS.7.2.1.3;

Other foreign financial transfers and aid in kind

Refinement of the categories of „public” and „private” (2)

Previously,

according to

WHO

guidelines

categorized

as private

fund

RoW financing

agents

Domestic

financing agents

RoW financing

scheme

Voluntary health

care payment

schemes

Governmental and

compulsory

contributory

scheme

Foreign

resources

Domestic

health care

provders

Foreign

health care

providers

GOVERNMENT

Flows of domestic resources

Flows of foreign resources

Domestic

resources

NGO

Flows from NGOs

Accounting foreign aid

Accounting foreign aid (2)

• intends to track as much as possible the route of the total foreign resource flows in the domestic health care system,

• includes not only health-specific aid, but an estimation (imputation) of the part of general budget aid; and other health-specific flows (without aid purposes),

• allows for developing a correspondence to the DAC statistics,

• distinguishes different types of foreign involvement (types of flows and types of institutional units, types of

providers

Issues to be discussed:

• To what extent can / should SHA 2011-based NHAs use the OECD DAC database?

Transition from SHA 1.0 to SHA 2011: HF

Distinguishing analytical units and statistical units:

• The categories of health financing schemes are the key analytical units of SHA 2011, concerning which data are collected from financing agents or providers

– including institutional units collecting the funds, if

they are different from agents paying the providers

Table 6.2. Mapping HF(SHA 1.0) to Classification of Financing Schemes under SHA 2011

SHA 1.0 SHA 2011

“Default” financing scheme Other financing

scheme

Revenues of HF

HF.1 General government

HF.1 Governmental schemes

and compulsory

contributory health

financing schemes

HF.1.1

General government

excluding social

security funds

HF.

1.1 Governmental schemes

HF.

1.1.1 Central government

HF.

1.1.1

Central governmental

schemes

HF.1.1.1 (A) HF.1.

1.1

Central governmental

schemes

HF.1.1.1 (B)

FS

1.4

Other transfers from

government

domestic revenue

HF.

1.1.2

HF.

1.1.2

State/regional/local

governmental schemes

HF.

1.1.3

State/provincial

government

Local/municipal

government

HF.

1.2

Compulsory contributory

health insurance schemes

HF.1.2 Social security funds HF.

1.2.1 Social health insurance

HF.1.2 (A)

HF.

1.2.1 Social health insurance

HF.1.2 (B)

HF.

1.2.2 Compulsory

private insurance

HF.1.2 (C)

HF.

2.1 Voluntary health

insurance

schemes

Transition from SHA 1.0 to SHA 2011: HF

FS.1 FS.2 FS.7

FS.1.1 FS.1.2 FS.1.3 FS.1.4

Tra

ns

fers

fro

m

Go

ve

rnm

en

t

do

me

sti

c r

ev

en

ue

Inte

rna

l tra

nsf

ers

an

d g

ran

tsT

ran

sfe

rs b

y

go

vern

me

nt

on

be

ha

lf o

f sp

eci

fic

Su

bsi

die

sO

the

r tr

an

sfe

rs

fro

m g

ove

rnm

en

t

do

me

stic

re

ven

ue

Tra

ns

fers

dis

trib

ute

d b

y

Go

ve

rnm

en

t fr

om

Dir

ec

t F

ore

ign

tra

ns

fers

FS.1General

government units

FS.1.1 Territorial

governments ΣGOV

ΣGOV -

(GOV 5+

GOV6) GOV1 GOV2 GOV3 GOV4 GOV5 GOV6

FS.1.2All otrher public

units

FS.2.1;

FS.2.3 Corporations and

NPISHs

FS.2.2 Households

FS.3 Rest of the world

Table 6.4 Mapping the FS (PG / JHAQ) categories to the categories of

Classification of Revenues of Health Financing Schemes

FS(PG/JHAQ)

Transition from SHA 1.0 to SHA 2011: FS

Preparation of SHA 2011-based health accounts

tables relevant to health care financing

Three-dimensional tables can be prepared for the following purposes:

• as working tables (i.e. only for technical reason) to produce HC x HF, HP x HF and HF x FS tables;

• analysis of the information gathered: completeness, consistency;

• as “output” tables, for analytical purpose also

Preparation of SHA 2011-based health accounts

tables relevant to health care financing

The following three-dimensional tables are proposed to prepare:

• Expenditure on health care by financing schemes, financing agents and providers (HF x FA x HP)

• Expenditure on health care by financing schemes, financing agents and health care function (HF x FA x HC)

• Revenues of financing schemes, by types of revenues and financing agents (FS x HF x FA)

Types of HF–FA relationship Compilation tasks

One-to-one correspondence

between HF(x) and FA(a) Data collected from FA(a) can be directly

filled into HFxFAxHC or HC x HF table

FA(a) manages two different

financing schemes: HF(x) and

HF(y)

Data on expenditure should be collected

(or estimated) separately for the

financing schemes managed by FA(a) (See

Table 7.4).

The allocation of administrative costs of

FA(a) according to the financing schemes

may require a specific estimation.

FA(a) manages HF(x), and in

addition an other social welfare

scheme (e.g., in-cash benefits,

such as sick leave or family

allowance, etc.)

Data on HF(x) should be separated from

the other activities of FA(a)

The HF(x)-related administrative costs of

FA(a) should be estimated.

Compilation tasks under different types of HF–FA

relationship

Accounting health care financing from the perspective of

the individual schemes and institutional units

Chapter 8 provides two related tools :

• a possible way to show the relationships between FS, HF and FA in the case of a particular financing scheme

• sectoral accounts (expenses and revenues for individual financing schemes, as well as individual institutional units)

Revenues of HF.1.1.1

Financing agents administering HF.1.1.1

FS.1

Transfers from Government domestic revenue (allocated to health purposes)

NCU FA.1.1.1 Ministry of Health NCU

FS.1.1 Internal transfers and grants

FA.1.1.2 Other Ministries and public units (belonging to central government)

FS.2

Transfers distributed by Government from foreign origin

FA.1.1.3 National Health Service Agency

FS.6 Other domestic revenues n.e.c.

FA.1.2 State /Regional / Local government

FS.6.1 Other revenues from households n.e.c.

FA.1.9 other general government units

FS.6.2 Other revenues from corporations n.e.c.

FA.3.1 Health management and provider corporations

FS.6.3 Other revenues from NPISH n.e.c.

FA.4 Non-profit Institutions serving households (NPISHs

FS.7 Direct Foreign transfers

HF.1.1.1. Central governmental schemes

Table 8.1 Central governmental schemes: types of revenues and

relevant financing agents

FS.1

Transfers from

government domestic

revenue (allocated to

health purposes) FS.1 FS.1

HP.

7

Providers of

health care

system

administration

and financing FS.3

Social insurance

contributions

HP.

7 FS.3

HP.

7 FS.3

HP.7

.1

Government health

administration

agencies FS.6 Other revenues n.e.c.

HP.7

.1 FS.6

HP.7

.1 FS.6

HP.7

.2

Social health

insurance agencies FS.7.1

Direct foreign financial

transfers

HP.7

.2 FS.7.1

HP.7

.2 FS.7.1

HP.7

.3

Private health

insurance

administration

agencies

HP.7

.3

HP.7

.3

HP.7

.9

Other

administration

agencies

HP.7

.9

HP.7

.9

RevenuesExpenses Expenses Revenues Expenses

Net/Gross operating

balance

Table 8.5 Sectoral accounts of Social health insurance schemes

(HF.1.2.1) Background tables to sectoral account of HF.1.2.1

Revenues and expenses of HF.1.2.1 Social health insurance

schemes (Md NCU)

HF.1.2.1 related Revenues

and expenses of National

Health Insurance Agency

HF.1.2.1 related Revenues

and expenses of Insurance

corporations (FA.2)

HP.1 to HP 6 HP.1 to HP 6

HP.1 to

HP 6

Revenues

Further steps (1)

• Financing Guidelines will be finalised based on the discussion of this Interim Report by

– a peer review group and

– participants of the 2011 OECD Meeting of Health Accounts Experts.

• The revised version will contain a summary of conclusions and/or recommendations in each chapter

Further steps (2)

• Preparation of specific country studies implementing some of the tools provided in this interim report (testing the advantages and feasibility of the given tools).

• Based on the country studies, the SHA 2011 Financing Guidelines will be further developed.

• Separate guidelines will be developed for the presentation of results from the implementation of the SHA 2011 accounting tools for health financing

Participating experts are invited to:

• COMMENT on the general approaches presented in the Interim report;

• COMMENT on the set of tools presented in the Interim report;

• PROPOSE further issues that need to be addressed under the Guidelines;

• EXPRESS an interest to participate in testing some of the tools proposed in the Guidelines.