SHA SHA –– ConceptsConcepts

Dr. Frank Dr. Frank CallejaCalleja M.D.M.D.Department of Health Information.Department of Health Information.

What is SHA?What is SHA?System of Health AccountsSystem of Health Accounts was published by was published by OECD in 2000 after a ten year project and study OECD in 2000 after a ten year project and study by National experts in health accounts in OECD by National experts in health accounts in OECD member countries.member countries.

SHA provides a standard framework for SHA provides a standard framework for producing a set of producing a set of comprehensivecomprehensive, , consistentconsistent, , and and internationally comparableinternationally comparable health care health care accounts which are compatible with and can be accounts which are compatible with and can be related to other national aggregate and social related to other national aggregate and social statistics.statistics.

SHA is designed to meet the needs of public and SHA is designed to meet the needs of public and private health analysts and policy makers.private health analysts and policy makers.

The standards embodied in the OECD system of The standards embodied in the OECD system of health accounts (SHA) have been adopted by health accounts (SHA) have been adopted by the European Union as the goals towards which the European Union as the goals towards which Member states are to work, and many nonMember states are to work, and many non--OECD countries have decided to use the SHA OECD countries have decided to use the SHA standards as the basis for their accounts as well. standards as the basis for their accounts as well.

The framework in SHA has also been The framework in SHA has also been adopted by WHO and EUROSTAT and both adopted by WHO and EUROSTAT and both organisations are now collecting health organisations are now collecting health care data in SHA formatcare data in SHA format

From a health policy perspective, SHAFrom a health policy perspective, SHA

Provides a framework for analysing health Provides a framework for analysing health systemssystems–– overall level of spending on health careoverall level of spending on health care–– changes in the composition of spendingchanges in the composition of spending–– monitoring factors of growth in health monitoring factors of growth in health

spendingspending–– differences across countries in expenditure differences across countries in expenditure

growth and composition of expendituregrowth and composition of expenditure

Provides a tool to monitor effects of health Provides a tool to monitor effects of health care reformscare reforms

SHA is not only about health expenditureSHA is not only about health expenditure

It is an overall framework for consistently It is an overall framework for consistently describing all aspects of health care describing all aspects of health care deliverydelivery

It defines the structure of a complete It defines the structure of a complete statistical system. This uses different statistical system. This uses different dimensions via classifications i.e. functions dimensions via classifications i.e. functions of health care (type of goods), provider, of health care (type of goods), provider, and funding.and funding.

SHA makes a clear separation between SHA makes a clear separation between the financial, institutional and functional the financial, institutional and functional aspects of health care by proposing a triaspects of health care by proposing a tri--axial system of recording answers to axial system of recording answers to three key questions:three key questions:

1.1. Where does the money come from? Where does the money come from? (financing source/(financing source/fundersfunders))

2.2. Where does the money go? (health care Where does the money go? (health care providers/actors/agencies:providers/actors/agencies:-- provide services provide services and goods)and goods)

3.3. What kind of functionally defined services are What kind of functionally defined services are performed and what types of goods are performed and what types of goods are purchased?purchased?

SHA manual proposes a “new” International SHA manual proposes a “new” International Classification for Health Accounts (ICHA) which Classification for Health Accounts (ICHA) which involves a triinvolves a tri--axial system of classifying the axial system of classifying the provision of health care:provision of health care:–– Functions of careFunctions of care –– ICHAICHA--HCHC (can be cross checked with SNA 93 (can be cross checked with SNA 93

classification)classification)

–– Health care Health care Service Provider Industries Service Provider Industries –– ICHAICHA--HP HP (can be cross checked with ISIC. Rev3 classification)(can be cross checked with ISIC. Rev3 classification)

–– Sources of FundingSources of Funding health care health care –– ICHAICHA--HFHF

Health expenditure is organised according to the Health expenditure is organised according to the above three main categories. Every part of above three main categories. Every part of expenditure is assigned to a specific function, expenditure is assigned to a specific function, provider, and source of funding.provider, and source of funding.

Classification of functions of health care Classification of functions of health care ––ICHAICHA--HCHC

HC.1HC.1 Services of curative careServices of curative care

HC.2HC.2 Services of rehabilitative careServices of rehabilitative care

HC.3HC.3 Services of long term nursing careServices of long term nursing care

HC.4HC.4 Ancillary services to healthcareAncillary services to healthcare

HC.5HC.5 Medical goods dispensed to outMedical goods dispensed to out--patientspatients

HC.6HC.6 Prevention and public health servicesPrevention and public health servicesHC.7HC.7 Health administration and health insuranceHealth administration and health insurance

HC.1 HC.1 –– HC.5: Personal health care servicesHC.5: Personal health care services

HC.6 HC.6 –– HC.7: Collective health care servicesHC.7: Collective health care services

Functions of personal health care are Functions of personal health care are classified by:classified by:

basic functions of carebasic functions of care

and by and by

mode of productionmode of production of careof care

Basic functions of careBasic functions of careCurative care (Curative care (akaaka acute care)acute care)The principal intent here is to: manage labour (Obstetrics), curThe principal intent here is to: manage labour (Obstetrics), cure illness or provide e illness or provide definitive treatment of injury, perform surgery, relieve symptomdefinitive treatment of injury, perform surgery, relieve symptoms of illness or injury, s of illness or injury, to reduce the severity of an illness or injury or to protect agato reduce the severity of an illness or injury or to protect against exacerbation and/or inst exacerbation and/or complications of an illness or injury which could threaten life complications of an illness or injury which could threaten life or normal function. or normal function.

Rehabilitative careRehabilitative careThe emphasis here is on improving the functional levels of the pThe emphasis here is on improving the functional levels of the persons served and ersons served and where the functional limitations are either due to recent illneswhere the functional limitations are either due to recent illness or injury or of a s or injury or of a recurrent nature. This type of care is usually less intensive threcurrent nature. This type of care is usually less intensive than acute (curative) care an acute (curative) care but more intensive than traditional nursing care.but more intensive than traditional nursing care.

Long term nursing careLong term nursing careThis comprises ongoing health and nursing care given to inThis comprises ongoing health and nursing care given to in--patients who patients who need assistance on a continuing basis due to chronic impairmentsneed assistance on a continuing basis due to chronic impairments and a and a reduced degree of independence and activities of daily living. Ireduced degree of independence and activities of daily living. It is typically t is typically a mix of medical and social services. a mix of medical and social services.

Mode of production of health careMode of production of health careInpatient careInpatient careCare delivered to patients who are formally admitted to an instiCare delivered to patients who are formally admitted to an institution for treatment tution for treatment or care and who stay for a minimum of one night in the institutior care and who stay for a minimum of one night in the institution providing care.on providing care.

Day careDay careMedical and paramedical services delivered to patients that are Medical and paramedical services delivered to patients that are admitted for admitted for diagnosis, treatment, or other types of health care with the intdiagnosis, treatment, or other types of health care with the intention of discharging ention of discharging the patient on the same day.the patient on the same day.

Outpatient careOutpatient careMedical and paramedical services delivered to outpatients. OutpaMedical and paramedical services delivered to outpatients. Outpatients are not tients are not formally admitted to the facility and do not stay overnight. An formally admitted to the facility and do not stay overnight. An outpatient is a person outpatient is a person who goes to a health care facility (not necessarily a hospital) who goes to a health care facility (not necessarily a hospital) for a consultation or for a consultation or treatment and who leaves the facility within a few hours treatment and who leaves the facility within a few hours In SHA, all visitors to ambulatory care facilities (physicians’ In SHA, all visitors to ambulatory care facilities (physicians’ private offices, private offices, hospital outpatient centre, health centres or other ambulatory chospital outpatient centre, health centres or other ambulatory care are centres) that are not day cases or over the night cases are conscentres) that are not day cases or over the night cases are considered as idered as out patients.out patients.

Home careHome careMedical and paramedical services delivered to patients at home.Medical and paramedical services delivered to patients at home. Includes obstetric Includes obstetric services at home, home visits by general practitioners, home diaservices at home, home visits by general practitioners, home dialysis. lysis. Excludes consumption of medical goods (pharmaceuticals & other gExcludes consumption of medical goods (pharmaceuticals & other goods) dispensed oods) dispensed to outpatients.to outpatients. Social services expenditures such as home making, home help and Social services expenditures such as home making, home help and meals on wheels are not part of expenditure on health in SHA.meals on wheels are not part of expenditure on health in SHA.

Personal Health Care Services (HC.1 Personal Health Care Services (HC.1 –– HC.5)HC.5)HC.1:HC.1: Services of Curative careServices of Curative care

HC.1.1: Inpatient curative careHC.1.1: Inpatient curative careHC.1.2: Day cases of curative careHC.1.2: Day cases of curative careHC.1.3: Out patient curative careHC.1.3: Out patient curative care

HC.1.3.1: Basic medical & diagnostic servicesHC.1.3.1: Basic medical & diagnostic servicesHC.1.3.2: Out patient dental careHC.1.3.2: Out patient dental careHC.1.3.3: All other specialised health careHC.1.3.3: All other specialised health careHC.1.3.9: All other out patient curative careHC.1.3.9: All other out patient curative care

HC.1.4: Services of curative home careHC.1.4: Services of curative home care

HC.2:HC.2: Services of rehabilitative careServices of rehabilitative careHC.2.1: Inpatient rehabilitative careHC.2.1: Inpatient rehabilitative careHC.2.2: Day cases of rehabilitative careHC.2.2: Day cases of rehabilitative careHC.2.3: Out patient rehabilitative careHC.2.3: Out patient rehabilitative careHC.2.4: Services of rehabilitative home careHC.2.4: Services of rehabilitative home care

HC.3:HC.3: Services of long term nursing careServices of long term nursing careHC.3.1: Inpatient long term nursing careHC.3.1: Inpatient long term nursing careHC.3.2: Day cases of long term nursing careHC.3.2: Day cases of long term nursing careHC.3.3: Long term nursing care: home careHC.3.3: Long term nursing care: home care

HC.4:HC.4: Ancillary services to health careAncillary services to health careHC.4.1: Clinical laboratoriesHC.4.1: Clinical laboratoriesHC.4.2: Diagnostic imagingHC.4.2: Diagnostic imagingHC.4.3: Patient transport and emergency rescueHC.4.3: Patient transport and emergency rescueHC.4.9: All other miscellaneous ancillary servicesHC.4.9: All other miscellaneous ancillary services

HC.5:HC.5: Medical goods dispensed to out patientsMedical goods dispensed to out patientsHC.5.1: Pharmaceuticals and other medical non durablesHC.5.1: Pharmaceuticals and other medical non durables

HC.5.1.1: Prescribed medicinesHC.5.1.1: Prescribed medicinesHC.5.1.2: Over the counter medicinesHC.5.1.2: Over the counter medicinesHC.5.1.3: Other medical non durablesHC.5.1.3: Other medical non durables

HC.5.2: Therapeutic appliances & other medical durablesHC.5.2: Therapeutic appliances & other medical durablesHC.5.2.1: Glasses & other vision productsHC.5.2.1: Glasses & other vision productsHC.5.2.2: Orthopaedic appliances & other prostheticsHC.5.2.2: Orthopaedic appliances & other prostheticsHC.5.2.3: Hearing aidsHC.5.2.3: Hearing aidsHC.5.2.4: MedicHC.5.2.4: Medic--technical devices including wheelchairstechnical devices including wheelchairsHC.5.2.9: All other miscellaneous medical durablesHC.5.2.9: All other miscellaneous medical durables

Collective health services (HC.6 Collective health services (HC.6 –– HC.7)HC.7)

HC.6:HC.6: Prevention & public health servicesPrevention & public health servicesHC.6.1: Maternal & child health; family planning & counsellingHC.6.1: Maternal & child health; family planning & counsellingHC.6.2: School medical servicesHC.6.2: School medical servicesHC.6.3: Prevention of communicable diseasesHC.6.3: Prevention of communicable diseasesHC.6.4: Prevention of nonHC.6.4: Prevention of non--communicable diseasescommunicable diseasesHC.6.5: Occupational health careHC.6.5: Occupational health careHC.6.9: All other miscellaneous public health servicesHC.6.9: All other miscellaneous public health services

HC.7:HC.7: Health administration & health insurancesHealth administration & health insurancesHC.7.1: General Government administration of health HC.7.1: General Government administration of health (except social security)(except social security)

HC.7.1.1: General Government administration of healthHC.7.1.1: General Government administration of healthHC.7.1.2: Administration, operation & support activities of SS fHC.7.1.2: Administration, operation & support activities of SS fundsunds

HC.7.2: Health administration and health insurance: PRIVATEHC.7.2: Health administration and health insurance: PRIVATEHC:7.2.1: Health administration & health insurance: social insurHC:7.2.1: Health administration & health insurance: social insuranceanceHC.7.2.2: Health administration & health insurance: other privatHC.7.2.2: Health administration & health insurance: other privatee

Health Related FunctionsHealth Related Functions

HC.R.1HC.R.1 Capital formation of health care Capital formation of health care provider institutionsprovider institutions

HC.R.2HC.R.2 Education & training of health personnelEducation & training of health personnelHC.R.3HC.R.3 Research & development in healthResearch & development in healthHC.R.4HC.R.4 Food, hygiene and drinking water Food, hygiene and drinking water

controlcontrolHC.R.5HC.R.5 Environmental healthEnvironmental healthHC.R.6HC.R.6 Administration & provision of social Administration & provision of social

services in kind to assist living with services in kind to assist living with disease and impairmentdisease and impairment

HC.R.7HC.R.7 Administration & provision of healthAdministration & provision of health--related related cash benefitscash benefits

Classification of providers of health care Classification of providers of health care ––ICHAICHA--HPHP

HP.1HP.1 Hospitals Hospitals

HP.2HP.2 Nursing & residential care facilitiesNursing & residential care facilities

HP.3HP.3 Providers of ambulatory health care Providers of ambulatory health care

HP.4HP.4 Retail sales & other providers of medical goods Retail sales & other providers of medical goods

HP.5HP.5 Provision & administration of public health Provision & administration of public health programmesprogrammes

HP.6HP.6 General health administration & insurance General health administration & insurance

HP.7HP.7 Other industries (rest of economy) Other industries (rest of economy)

HP.9HP.9 Rest of the worldRest of the world

ICHA ICHA –– HP Classification (1)HP Classification (1)HP.1:HP.1:HospitalsHospitals

HP.1.1: General hospitalsHP.1.1: General hospitalsHP.1.2: Mental health & substance abuse hospitalsHP.1.2: Mental health & substance abuse hospitalsHP.1.3: Speciality hospitalsHP.1.3: Speciality hospitals

HP.2:HP.2:Nursing & residential care facilitiesNursing & residential care facilitiesHP.2.1: Nursing care facilitiesHP.2.1: Nursing care facilitiesHP.2.2: Residential mental retardation, mental health & substancHP.2.2: Residential mental retardation, mental health & substance abuse e abuse

facilitiesfacilitiesHP.2.3: Community care facilities for the elderlyHP.2.3: Community care facilities for the elderlyHP.2.9: All other residential care facilitiesHP.2.9: All other residential care facilities

HP.3:HP.3:Providers of ambulatory health careProviders of ambulatory health careHP.3.1: Offices of physiciansHP.3.1: Offices of physiciansHP.3.2: Offices of dentistsHP.3.2: Offices of dentistsHP.3.3: Offices of other health practitionersHP.3.3: Offices of other health practitionersHP.3.4: Out patient care centresHP.3.4: Out patient care centres

HP.3.4.1: Family planning centresHP.3.4.1: Family planning centresHP.3.4.2: Out patient mental health & substance abuse centresHP.3.4.2: Out patient mental health & substance abuse centresHP.3.4.3: FreeHP.3.4.3: Free--standing ambulatory surgery centresstanding ambulatory surgery centresHP.3.4.4: Dialysis care centresHP.3.4.4: Dialysis care centresHP.3.4.5: All other out patient multiHP.3.4.5: All other out patient multi--speciality & cospeciality & co--operative service centresoperative service centresHP.3.4.9: All other out patient community & other integrated carHP.3.4.9: All other out patient community & other integrated care centrese centres

HP.3.5: Medical & diagnostic laboratoriesHP.3.5: Medical & diagnostic laboratoriesHP.3.6: Providers of home health care servicesHP.3.6: Providers of home health care servicesHP.3.9: Other providers of ambulatory health careHP.3.9: Other providers of ambulatory health care

HP.3.9.1: Ambulance servicesHP.3.9.1: Ambulance servicesHP.3.9.2: Blood and organ banksHP.3.9.2: Blood and organ banksHP.3.9.9: Providers of all other ambulatory care servicesHP.3.9.9: Providers of all other ambulatory care services

ICHA ICHA –– HP Classification (2)HP Classification (2)

HP.4:HP.4: Retails sales and other providers of medical goodsRetails sales and other providers of medical goodsHP.4.1: Dispensing chemistsHP.4.1: Dispensing chemistsHP.4.2: Retail sales & other suppliers of optical glasses and otHP.4.2: Retail sales & other suppliers of optical glasses and other vision productsher vision productsHP.4.3: Retail sales and other suppliers of hearing aidsHP.4.3: Retail sales and other suppliers of hearing aidsHP.4.4: All other miscellaneous sales & other suppliers of otherHP.4.4: All other miscellaneous sales & other suppliers of other medical appliancesmedical appliancesHP.4.9: All other miscellaneous sales & other suppliers of pharmHP.4.9: All other miscellaneous sales & other suppliers of pharmaceuticals & medical aceuticals & medical

goodsgoods

HP.5:HP.5: Provision & administration of public health programmesProvision & administration of public health programmes

HP.6:HP.6: General health administration & insuranceGeneral health administration & insuranceHP.6.1: Government administration of healthHP.6.1: Government administration of healthHP.6.2: Social security fundsHP.6.2: Social security fundsHP.6.3: Other social insuranceHP.6.3: Other social insuranceHP.6.4: Other insurance HP.6.4: Other insurance –– privateprivateHP.6.9: All other providers of health administrationHP.6.9: All other providers of health administration

HP.7:HP.7: Other industries (rest of the economy)Other industries (rest of the economy)HP.7.1: Establishments as providers of occupational health serviHP.7.1: Establishments as providers of occupational health servicescesHP.7.2: Private households as providers of home careHP.7.2: Private households as providers of home careHP.7.9: all other industries as secondary producers of health caHP.7.9: all other industries as secondary producers of health carere

HP.9:HP.9: Rest of the worldRest of the world

Classification of health care financing Classification of health care financing ––ICHAICHA--HFHF

HF.1HF.1 General GovernmentGeneral Government

HF.2HF.2 Private sector Private sector

HF.3HF.3 Rest of the worldRest of the world

ICHA ICHA –– HF ClassificationHF ClassificationHF.1:HF.1: General GovernmentGeneral Government

HF.1.1: General Government excluding social security fundsHF.1.1: General Government excluding social security fundsHF.1.1.1: Central GovernmentHF.1.1.1: Central GovernmentHF.1.1.2: State/provincial governmentHF.1.1.2: State/provincial governmentHF.1.1.3: Local/municipal governmentHF.1.1.3: Local/municipal government

HF.1.2: Social Security fundsHF.1.2: Social Security funds

HF.2:HF.2: Private sectorPrivate sectorHF.2.1: Private social insuranceHF.2.1: Private social insuranceHF.2.2: Private insurance enterprises (other than social insuranHF.2.2: Private insurance enterprises (other than social insurance)ce)HF.2.3: Private household out of pocket expenditureHF.2.3: Private household out of pocket expenditure

HF.2.3.1: Out of pocket excluding cost sharingHF.2.3.1: Out of pocket excluding cost sharingHF.2.3.2: Cost sharing: central governmentHF.2.3.2: Cost sharing: central governmentHF.2.3.3: Cost sharing: state/provincial governmentHF.2.3.3: Cost sharing: state/provincial governmentHF.2.3.4: Cost sharing: local/municipal governmentHF.2.3.4: Cost sharing: local/municipal governmentHF.2.3.5: Cost sharing: social security fundsHF.2.3.5: Cost sharing: social security fundsHF.2.3.6: Cost sharing: private social insuranceHF.2.3.6: Cost sharing: private social insuranceHF.2.3.7: Cost sharing: other private insuranceHF.2.3.7: Cost sharing: other private insurance

HF.2.4: Non profit institutions serving households (other than sHF.2.4: Non profit institutions serving households (other than social insurance)ocial insurance)HF.2.5: Corporations (other than health insurance)HF.2.5: Corporations (other than health insurance)

HF.3HF.3 :: Rest of the worldRest of the world

Expenditure & CostsExpenditure & CostsExpenditure is by definition not identical to cost.Expenditure is by definition not identical to cost.Investment outlays are part of expenditure but not of the costs;Investment outlays are part of expenditure but not of the costs; depreciation, depreciation, however, is part of the cost of the production process but doeshowever, is part of the cost of the production process but does not constitute not constitute expenditure.expenditure.

Total health care expenditureTotal health care expenditure represents the financial burden on represents the financial burden on society for having and maintaining a health care system. It inclsociety for having and maintaining a health care system. It includes the udes the sums of capital investment and health care costs.sums of capital investment and health care costs.

Health care costsHealth care costs (running costs) for society for having a health care (running costs) for society for having a health care system comprise the sums of valuing the resources to produce heasystem comprise the sums of valuing the resources to produce health care lth care services together with their associated operation and managementservices together with their associated operation and management. . Where, as in the case of private health care providers, health cWhere, as in the case of private health care providers, health care are producers have to finance their investment out of their receiptsproducers have to finance their investment out of their receipts, running , running costs should also include the depreciation of the capital goods costs should also include the depreciation of the capital goods used in the used in the provision of health care. This is not the case in State health cprovision of health care. This is not the case in State health care providers are providers where Government supplies investment goods directly free of charwhere Government supplies investment goods directly free of charge or ge or supplies the financial means for investment.supplies the financial means for investment.

In SHA, In SHA, Total current health expenditureTotal current health expenditure represents health care represents health care running costs.running costs.

Expenditure on health careExpenditure on health care

Total Health ExpenditureTotal Health Expenditure = sum of expenditures = sum of expenditures by the financing agents (government, insurance by the financing agents (government, insurance companies, establishments and consumers) + companies, establishments and consumers) +

investment subsidies and investments in kind.investment subsidies and investments in kind.

Total Current Health ExpenditureTotal Current Health Expenditure (Running costs (Running costs of health care/recurrent expenditure ) = sum of of health care/recurrent expenditure ) = sum of all costs incurred by all health care providers all costs incurred by all health care providers including depreciation, where applicable, BUT including depreciation, where applicable, BUT excluding payments for investments.excluding payments for investments.

Expenditure Concepts Expenditure Concepts -- SHASHA

Total expenditure on healthTotal expenditure on healthHC.1 HC.1 –– HC.7 (TCHE) + HC.R.1HC.7 (TCHE) + HC.R.1

THETHE

Preventive and public health servicesPreventive and public health servicesHC.6HC.6

Health administration and health Health administration and health insuranceinsurance

HC.7HC.7

Total current expenditure on Total current expenditure on health (Recurrent expenditure)health (Recurrent expenditure)

HC1 HC1 –– HC7HC7 (TCHE)(TCHE)

DescriptionDescriptionICHA codesICHA codes

Gross capital formation in health care Gross capital formation in health care industries (Capital expenditure)industries (Capital expenditure)

HC.R.1HC.R.1

Medical good dispensed to out Medical good dispensed to out patientspatients

HC.5HC.5

Personal health care servicesPersonal health care servicesHC.1 HC.1 –– HC.4HC.4

Total personal health expenditureTotal personal health expenditureHC.1 HC.1 –– HC.5HC.5 (TPHE)(TPHE)

Health ExpenditureHealth ExpenditureHierarchical Structure of Health DataHierarchical Structure of Health Data

Total Current HE (TCHE): Recurrent HE – HC.1 – HC.7/ Investment: Capital exp. – HC.R.1 / Collective HE: Preventive& Public Health services and Health Administration/insurance: HC.6 - HC.7/ TCHE: Personal HE (HC.1 – HC.5) + Collective HE (HC.6 – HC.7)