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INFORMING POLICY WITH HEALTH ACCOUNTS
Michael Müller, OECD Health Division
2nd HEALTH SYSTEMS JOINT NETWORK MEETING FOR CENTRAL, EASTERN AND SOUTHEASTERN EUROPEAN COUNTRIES Tallinn, 1-2 December, 2016
Health Accounts –What is it?
Early and country specific efforts
Develop-ment of
NHA methods
• First HA standard; base for NHA “Producers Guide”; Disease-based accounts
SHA 2011
SHA 1.0
• Joined Global Standard; legal framework in EU
• Country studies; US National Health Accounts
• System of National Accounts (SNA); OECD Health Data
Who pays?
What services?
Who provides
?
Framework to measure health spending and financing
History:
SHA 2011 Framework
Current Health
Spending
Consumer health interface
Financing interface Provision interface
Functions ICHA-HC
Financing schemes ICHA-HF Providers ICHA-HP
Characteristics of beneficiaries (Disease, age, gender, income, etc.)
Financing Agents ICHA-FA Revenues of Financing Schemes ICHA - FS
Factors of Provision ICHA-FP External trade
Gross capital formation
non-health expenditure
Health-related expenditure
Current health spending
MOH
Boundary definition
PURPOSES OF HEALTH ACCOUNTS
4
Health accounts sits at the centre of health system analysis
Health Accounts
Quality of services
Accessibility
Equity of utilisation
Efficiency of the
system
Transparency and
accountability
Innovation
Health
Equity in health
Financial risk protection
Responsiveness
Governance stewardship
Resource
generation human, physical, and knowledge
Financing collecting,
pooling and purchasing
Service delivery
personal and population-based
Health system functions
Instrumental objectives
Ultimate objectives
Health care
Consumption
Financing Provision
Source: SHA 2011
The main purposes of SHA
To define harmonised boundaries of health care for tracking expenditure on consumption
HEALTH CARE
Prevention and Public Health
Long-term Care
Medical goods
Outpatient care
Inpatient care
To provide a framework of the main aggregates relevant to international comparisons of health expenditures and health systems analysis
Administration
To provide a tool, expandable by individual countries, which can produce useful data in the monitoring and analysis of the health system
Assuring internationally comparable data
Source: OECD Health Statistics 2015
16.4
11
.1
11.1
11
.0
11.0
10
.9
10.4
10
.2
10.2
10
.2
10.1
9.
9 9.
5 9.
2 9.
1 9.
1 8.
9 8.
9 8.
9 8.
8 8.
8 8.
8 8.
7 8.
7 8.
6 8.
5 8.
1 7.
6 7.
5 7.
4 7.
3 7.
1 6.
9 6.
8 6.
6 6.
5 6.
4 6.
2 6.
1 6.
0 5.
6 5.
3 5.
1 4.
0 2.
9
0
2
4
6
8
10
12
14
16
18% GDP Public Private
21 19 18 18 18
16 16 16 15 15 15 15 14 13 13 12 12 12 12 12 12 12 11 11 10 10 10 9 6
22
17 16
14 13 11 9
8
0
5
10
15
20
25% total government expenditure
16 January 2000 TONY BLAIR: ...then at the end of that five
years we will be in a position where our Health Service spending comes up to the average of the European Union, it’s too low at the moment so we’ll bring it up to there.
DAVID FROST: Bring it up to there by when?
TONY BLAIR: At the end of that five year period, in other words if…
DAVID FROST: Five years from today not five years from the next election, five years from…
TONY BLAIR: No five years from the end of this financial year,...
Simple comparisons of aggregates used for benchmarking!
United Kingdom
EU-15
5
5.5
6
6.5
7
7.5
2000 2001 2002 2003 2004 2005 2006 2007 2008
Public spending on health (%of GDP)
Health Spending Analysis: OECD average as a starting point for comparative analysis to show the trend in health spending
-1%
0%
1%
2%
3%
4%
5%
6%
2001 2004 2007 2010 2013
OECD OECD (EU) OECD (non-EU)
Average annual growth in total health expenditure per capita, in real terms, 2001 to 2013
Source: OECD Health Statistics 2015
Average OECD health expenditure growth rates in real terms
Health Spending Analysis: Country level data point to large variations across OECD countries and direction for further investigation
5.4
-0.4
5.3
1.3
3.5
0.5
3.4
0.4
3.2
5.4
3.6
3.5
6.7
3.2 3.4
11.3
4.1
-2.3
1.5 2.
2
1.7
5.0
1.9
1.7 2.
3
3.3
1.7
2.9
2.8
8.4
1.3 1.
9
3.2
9.0
5.9
-7.2
-4.3
-4.0
-3.0
-1.7
-1.6
-0.8
-0.4
-0.3
-0.2
-0.1
0.3
0.3 0.5
0.6
0.6
0.6 0.8
0.9 1.0
1.0 1.2
1.2
1.3 1.5 1.7
1.7 2.0
2.0 2.3 2.5
3.6 3.9
5.4
6.4
-10
-5
0
5
10
152005-2009 2009-2013
Source: OECD Health Statistics 2015
Health Spending Analysis: Breaking spending down by components can start to tell a story
Average growth by main function per capita, OECD average, 2005-2013, in real terms
-3%
-2%
-1%
0%
1%
2%
3%
4%
5%
6%
7%
Inpatient care Outpatient care Long-term care Pharmaceuticals Prevention Administration
2005-09 2009-13
Source: OECD Health Statistics 2015
SHA plays key role in monitoring financial sustainability US
AGR
EECE
CAN
IREL
AND
FRA
BEL
DEU
JPN
ITA
ESP
PRT
AUT
AUS
CHE
SVK
SWE
ISL
HUN
FIN
SVN
LUX
NOR
KOR
GBR
CZE
DNK
POL
NZL
EST
MEX
200
400
600
800
Per capita spending in USD PPP, 2007
Health spending analysis: Evaluation of reforms and impact of governance changes
Average per capita inpatient expenditure growth rates (in real terms), OECD average, 2005-2011
0 1 2 3 4 5 6
General government/Social security
Private out-of-pocket
Private insurance
2005-07 2007-09 2009-11 2011-13
In %
Source: OECD Health Statistics 2015
Health spending analysis: Explaining factors that differentiate the level of health spending
0.53
0.60 0.57
0.47
0.53
0.81
0.70 0.67
0.64
0.54
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
Germany Switzerland Netherlands France Canada
Adjusted fordifferences ineconomy-wideprice levels
Adjusted fordifferences inhealth sectorprice levels
United States
Comparison of per capita health expenditure estimated using general price levels and health-specific price levels (United States=1), 2011
OECD analysis on comparative price levels in
health suggests prices rather than volumes contribute to
high US spending.
because of…
Intense use of health-related technologies, low productivity,
decentralised price negotiations, fragmentation in
the insurance market, high level of provider concentration
and weak price control
Application of Health Accounts – spending by disease
0 10 20
CirculatoryDigestive
Mental healthMusculoskeletalNervous system
CancerEndocrine
RespiratorySymptoms
InjuriesGenitourinary
OtherfactorsInfectious
SkinPregnancyCongenital
BloodPerinatalExternal
GERMANY, 2008 0 10 20
CirculatoryDigestive
RespiratoryCancer
MusculoskeletalNervous system
InjuriesInfectious
Mental healthGenitourinary
EndocrineSkin
SymptomsOtherfactors
PregnancyBlood
CongenitalPerinatal
KOREA, 2009 NETHERLANDS, 2011 0 10 20
Mental healthNot allocated
CirculatoryDigestive
MusculoskeletalNervous system
CancerSymptoms
RespiratoryGenitourinary
EndocrineInjuries
PregnancySkin
InfectiousBlood
CongenitalPerinatal
Source: OECD Exp. by Disease, Age and Gender Database.
Application of Health Accounts – forecasting, sustainability & equity
OECD comparative studies linking financing data from SHA with utilisation data to measure inequalities
Using Public Health Spending Data as a starting point to project spending growth
SHA 2011: A FOCUS ON FINANCING
17
The SHA 2011 Financing Framework
Financingagent(FA)
Financingagent(FA)
Institutional units of the economy
providing revenues
Financingagent(FA)
Providers(HP)
Functions(HC)
Financingscheme
(HF)
Financingscheme
(HF)
Basic structural relationships of health financing
Money flow
• refined framework to mirror the evolution in financing and align with the financing functions of collection, pooling and purchasing
• Financing schemes and related financing agents
• The basic flows: (i) revenue-raising and (ii) allocation of resources
Health Care Financing: Main Questions SHA 2011 can help to answer
• How is financing in a country’s health care sector structured and how is it managed?
• How does a particular health financing scheme collect its revenues? • What is the extent of external funding? • Where does the money go? • How are the particular health care services or goods financed? • What share of the spending on inpatient care is covered by out-of-
pocket (OOP) payments? • How are the resources of the different financing schemes allocated
among the different groups of beneficiaries, such as by disease?
Revised classification of schemes and a focus on revenues
Classification of financing schemes (HF)
HF.1 Government schemes and compul. contrib. health care financing schemes
HF.1.1 Government schemes
HF.1.2 Compul. contrib. health insurance schemes
HF.1.2.1 Social health insurance
HF.1.2.2 Compulsory private insurance
HF.2 Voluntary health care payment schemes
HF.2.1 Voluntary health insurance schemes
HF.2.2 NPISH financing schemes
HF.2.3 Enterprise financing schemes
HF.3 Household out-of-pocket payment
HF.4 Rest of the world financing schemes
Classification of revenues of financing schemes (FS)
FS.1 Transfers from government domestic revenue
FS.1.2 … on behalf of specific groups
FS.1.3 Subsidies
FS.2 Transfers distributed by government from foreign origin
FS.3 Social insurance contributions
FS.3.1 ... from employees
FS.3.2 ...from employers
FS.3.3 ...from self-employed
FS.4 Compulsory prepayment (other than FS.3)
FS.5 Voluntary prepayment
FS.6 Other domestic revenues n.e.c.
FS.7 Direct foreign transfers
New Framework sheds better light on government involvement
Tracking revenues: Policy relevance
0%
25%
50%
75%
100%Other Soc. Ins. Contributions Govt. Transfers•Track diversification of revenue
sources for health financing e.g. away from payroll-based contributions in the face of changing demographics
•Refine definitions and improve overall country coverage to feed work on fiscal sustainability and expenditure forecasting
•Measure the full burden of government spending on health taking into account subsidies and transfers to other financing schemes
0102030405060
2000 2002 2004 2006 2008 2010 2012 2014
tril
lion
s Revenues Expenditures
NHA can help assessing health system performance
• Transparency and accountability - Where does the money come
from, who manages it and what is it used for ?
• Financial risk protection – levels of out-of-pocket spending /pre-
payments
• Accessibility and equity – by beneficiary characteristics with
other non-expenditure data (e.g. Utilisation)
• Efficiency – by function with data on activities, outcomes. But:
• NHA not an end in itself but should follow country priorities
• Insufficient on their own to assess programme interventions
• Cannot answer questions it is not designed to accommodate
Problems with budget process, formulation, execution? other instruments: PER, PETS
What information can health accounts provide?
• Internationally comparable data on the overall level and growth and composition of spending on health care
– International benchmarking
– Compare and relate spending with priorities
• Deeper analytic possibilities of
– how services are financed and provided
– Factors that drive growth in health spending
– Financial sustainability (for schemes & health system)
– tracking of domestic and external sources of financing
– Evaluation of reforms and impact of governance changes
– Achievement of Universal Health Coverage on regional level
• SHA 2011 is intended as a reference guide and a flexible toolkit
priorities and policy uses can differ and should be up to countries
Contact: [email protected]
Read more about our work Follow us on Twitter: @OECD_Social
Website: www.oecd.org/health
Newsletter: http://www.oecd.org/health/update
Thank you