System of Health Accounts

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 - 2019 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.

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.

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 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".
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 2015/359 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.

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).

Territory of the Republic of Bulgaria.

2010 - 2013 (data according to the SHA, ver.1.0);
2011 - 2019 (data according to the SHA, ver. 2011).

Not applicable.

• 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;
• 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.

Annually

Exhaustive for all units.

The data is provided to Eurostat, WHO and OECD in accordance with the deadline set out in Commission Regulation 359/2015. Once the validation process has been successfully completed, the data is published - T + 22 months

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.

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

Not applicable.

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.

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.

In accordance with the requirements of Commission Regulation 1338/2008 every five years is provided the a report on the quality.

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.

Data users are state and regional authorities, international organisations, national and foreign users.

NSI conducts a regular statistical survey "Users' satisfaction" which covers all statistical domains. It aims to assess user satisfaction in NSI data provision and to outline the recommendations for future development of statistical system according to the needs of the users.

For the compulsory variables of the HC categories - the category HC.2.4 "Home-based rehabilitative care" is reported in HC2.3 "Outpatient rehabilitative care". The categories HC.3.2 "Day long-term care (health)" and HC. 3.3 "Outpatient long-term care (health)" are missing. The day long-term care as well as outpatient long-term care are part of the duties of GPs or specialists and the expenditures are reported in HC1.

Table HPxHF = 90.9%

Table HCxHP = 86.7%

Table HCxHF = 79.3%

The quality of the data depends significantly on the quality of the primary data sources.

Not applicable.

Not applicable.

Not applicable.

Overcoverage - Health care goods and services by non-residents are included.

Undercoverage - There is some underestimation of the LTC expenditure. The distinction between health and social long-term care in Bulgaria is based on national legislation and NACE classification. Within health care, only hospices provide long-term health care as a main function.  Palliative care in hospitals have been classified as curative care as a function, rather than long-term care. Homes for the disabled and elderly – which come under social care establishments – do not provide on-site medical care.  Medical treatment is provided under contract by GPs and other specialists, as for the rest of the population. All other community and residential services come under the umbrella of social services.

An under-coverage exists in OOP payments. Underground/informal/illegal health services and goods are not included. At this stage we are not able to report these payments.

Overcoverage - Health care goods and services by non-residents are included.

Undercoverage - There is some underestimation of the LTC expenditure. The distinction between health and social long-term care in Bulgaria is based on national legislation and NACE classification. Within health care, only hospices provide long-term health care as a main function.  Palliative care in hospitals have been classified as curative care as a function, rather than long-term care. Homes for the disabled and elderly – which come under social care establishments – do not provide on-site medical care.  Medical treatment is provided under contract by GPs and other specialists, as for the rest of the population. All other community and residential services come under the umbrella of social services.

An under-coverage exists in OOP payments. Underground/informal/illegal health services and goods are not included. At this stage we are not able to report these payments.

If double-counting of expenditure is detected it is removed and consolidated.

National data validation is carried out - analysis of trends, growth rates and anomalies. In case of errors detected, the data are revised.

Not applicable.

Not applicable.

Not applicable.

National data validation is carried out - analysis of trends, growth rates and anomalies and cross-validation between different data sources. In case of errors detected, the data are revised.

Not applicable.

Not applicable.

Not applicable.

There are two main types of revisions:

• The first type of audits is ongoing when a new or updated statistical information based on statistical surveys or administrative sources is available.
• The second type of revisions is related to a change in the methodology and calculation procedures.

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.

Changes resulting from data revisions in the last years range from -0.1% to + 0.04% (grow rates) depending on the kind of revision - refers to the period covered by the last quality report (2014-2016).

The data are provided to Eurostat, WHO and OECD in accordance with the deadline set out in Commission Regulation 359/2015. Once the validation process has been successfully completed, the data is published - T + 22 months

Not applicable.

Data are disseminated according to the Release Calendar presenting the results of the statistical surveys carried out by the National Statistical Institute.

Transmission to Eurostat, WHO and OECD: 30 April in year t for figures on year t-2.

Not applicable.

Not applicable.

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

2011 - 2019 - data according to the SHA, ver. 2011. 

Since 2013, there is a break in time series. The data are comparable for the period 2013 – 2019.

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

2011 - 2019 - data according to the SHA, ver. 2011. 

Since 2013, there is a break in time series. The data are comparable for the period 2013 – 2019.

The SHA figures can be reconciled with figures from Business statistics. A full coherence between SHA and ESSPROS is not feasible. Compilation methods for SHA and ESSPROS are different for Bulgarian NSI and therefore data cannot be mapped.

Not applicable.

Coherence in accounting principles exist. However, as differences in the scope and the concepts used by SHA and National accounts exist, a full coherence is 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.

Atypical entries:

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 applicable.

Not available.

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

Not applicable.

• 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.

Not applicable.

• 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.