Introduction

This is the official publication by CSO of current health care expenditure for Ireland according to the international standard of the System of Health Accounts, 2011. The publication provides a detailed profile of Irish current health expenditure according to the classifications of the functions of health care (ICHA-HC), health care provision (ICHA-HP), financing schemes (ICHA-HF) and revenues of financing schemes (ICHA-FS). This level of detail is available from 2011.

The 2018 SHA publication is in a new format. The list of individual chapters allows the user to review all the data with ease. There are also additional graphs and detail in some of the tables. Please send any feedback to sha@cso.ie as we continue to improve this publication.

International comparisons for SHA data:

• Eurostat
  • Eurostat database under the theme Population and Social Conditions/Health/Health Care/Health Care Expenditure, see Eurostat Database.
  • Eurostat presents key statistics on expenditure and financing aspects of healthcare in the European Union (EU), see the Statistics Explained section of the Eurostat website, see Statistics Explained - Healthcare Expenditure statistics.
• OECD
  • OECD database under the theme Health Resources/Health spending, see Health Spending
  • The OECD publishes Health at a Glance every year which compares key indicators for population health and health system performance across OECD members, see Health at a Glance section of the OECD iLibrary, see Health at a Glance.
• WHO 
  • The WHO has a Global Health Expenditure database with access to SHA data, under the theme Health Topics/Health Financing, see  WHO Global Health Expenditure Database.

Overview of the System of Health Accounts

What is the System of Health Accounts?

The System of Health Accounts (SHA) was devised by the Organisation for Economic Co-operation and Development (OECD) and has been adopted for joint reporting of health care expenditure by the OECD, Eurostat and the World Health Organisation.  It is an extension of the core National Accounts and consists of a family of interrelated tables for reporting expenditure on health and its financing. 

The SHA contains common concepts, definitions, classifications and accounting rules to enable comparability over time and across countries.  It provides a basis for uniform reporting by countries with a wide range of different models of organising their national health systems.  The SHA also draws a commonly defined boundary around what is health care and distinguishes it from related social care services.  This is particularly important for international comparisons given the diversity in health and social care services provision and their funding across Europe and the rest of the world.

The provision of health care and its funding is a complex, multi-dimensional process.  The set of core tables in the SHA addresses three basic questions:

1. Where does the money to finance the health system come from? (Financing schemes);
2. Who does the money go to? (Provider of health care services and goods);
3. What kinds of (functionally defined) services are performed and what type of goods are purchased?

Consequently, the SHA is organised around a tri-axial system for the recording of health expenditure, by means of the International Classification for Health Accounts (ICHA), defining;

• Health care financing schemes (ICHA-HF);
• Health care by service provider industries (ICHA-HP);
• Health care by function (ICHA-HC).

In addition to the core tables outlined above the OECD requests other data. This year Ireland has provided data on Revenues of Health Care Financing Schemes (ICHA-FS), further detail on this is below. We have also prepared provisional estimates of 2019 data. Summary details of the categories in each classification are given in the section below, International Classification of Health Accounts and linked documents.  A detailed description of the classifications and their application is set out in the manual on the System of Health Accounts which is available in the Products Manuals and Guidelines section of the Eurostat website, see SHA manual.

International Classification of Health Accounts

This section provides some detail on each classification.  Details of the current application of the standard in Ireland  are available in metadata which is in the System of Health Accounts methodology section, see methodology.

ICHA – HF:  Health Care Financing Schemes

Health care financing schemes are structural components of health care financing systems.  They are the main types of financing arrangements through which people obtain health services.  These include:

• Government schemes
• Compulsory contributory health insurance
• Voluntary health insurance
• Other financing arrangements in which participation is voluntary
• Out-of-pocket expenditure by households.

ICHA – HP: Classification of Health Care Providers

The classification of health care providers (ICHA-HP) classifies all organisations that contribute to the provision of health care goods and services, by arranging country-specific provider units into common, internationally applicable categories. The “principal activity” undertaken is the basic criterion for classifying health care providers. These include:

• Hospitals
• Residential long-term care facilities (e.g. for older people or for people with a disability)
• Ambulatory health care providers (e.g. GPs, dentists)
• Ancillary service providers (e.g. transport, emergency rescue, laboratory services)
• Retailers and other providers of medical goods (e.g. pharmacies)
• Providers of preventive care (e.g. organisation of public health programmes)
• Providers of health care administration and financing
• Other providers (e.g. households, other industries, rest of world)

ICHA – HC: Classification of Health Care Functions Explained

The functional classification under the SHA is the key classification for defining the boundary of health care. It groups health care services by purpose.  The first five categories relate to goods and services consumed by individuals.  These categories comprise

• Curative and rehabilitative care – where the principal intent is to:
  • Relieve symptoms of illness or injury, to reduce the severity of an illness or injury, or to protect against exacerbation and/or complication of an illness and/or injury that could threaten life or normal functioning; and/or
  • To empower persons with health conditions who are experiencing or are likely to experience disability so that they can achieve and maintain optimal functioning, a decent quality of life and inclusion in the community and society.
• Long-term care (health) – which consists of a range of medical and personal care services with the primary goal of alleviating pain and suffering and reducing or managing the deterioration in health status in patients with a degree of long-term dependency.  The SHA distinguishes between long-term care with a “health” purpose and long-term care with a “social” purpose.  As these elements of long-term care are often delivered in a single package of care, it is difficult to separate them.
• Ancillary services such as laboratory services, imaging services, patient transport and emergency rescue.  Data is reported explicitly in this category only when the services are received independently of an overall episode of health care – the majority of these services are recorded as part of curative and rehabilitative or long-term care and are not separately identified.
• Medical goods dispensed to outpatients – by a health care establishment or by a retailer of medical goods.  Like ancillary services, those goods consumed as part of other functions are not identified separately.

Two other categories relate to the collective consumption of health care, namely:

• Prevention and public health services – such as information, education and counselling programmes, immunisation programmes, screening programmes and disease surveillance.
• Health administration and governance – includes the formulation and administration of government policy; the setting of standards; the regulation, licensing or supervision of producers.  These activities are mainly carried out by governments but may also be provided by private bodies such as health insurers and advocacy/representative groups.

ICHA – FS: Classification of Revenues of Health Care Financing Schemes

Revenue is an increase in the funds of a health care financing scheme, through particular contribution mechanisms. The categories of the classification are the particular types of transaction through which the financing schemes obtain their revenues. For Ireland these include:

• Transfers from government domestic revenue
• Social insurance contributions from employees
• Social insurance contributions from employers
• Social insurance contributions from self-employed
• Voluntary prepayment from household
• Other revenues from households

National application of the SHA standard

Much progress has been made in the coding of data sources to the SHA classifications. However this work is ongoing and revisions, especially to the more detailed profile of the data are to be expected. 

Specific known data issues

All HSE hospital expenditure funded by HSE Mental Health Services has been allocated to HP.1.2 Mental Health Hospitals. 

Expenditure included under the SHA reporting standard should relate to Final Consumption Expenditure (FCE) only.  The expenditure included in this publication includes some items that should not be included in FCE e.g. interest payments.  This deviation is not material.

Coverage

Non-Profit Providers: There is ongoing work to improve the coverage of data on expenditure on health care.  In particular, further development work on non-profit providers of health care and their non-government funding is ongoing.  The funding of health care services from non-profit institutions serving households financing schemes (HF.2.2) is under represented in the current data and will be revised in future data reporting.

Residents and Non-Residents:  Health expenditure should relate only to residents of the Republic of Ireland.  Most data sources do not capture information on residence and thus expenditure on non-residents may be included in the data (export of health care services).  Expenditure by residents in other countries is also difficult to capture, particularly out-of-pocket expenditure.  Some expenditure funded by the HSE and private health insurers has been captured.  There is likely to be an underestimate of import (purchasing of healthcare abroad) of health care services in the Irish SHA data. 

Health Care/Social Care Boundary: The project to implement the SHA reporting standard in Ireland reviewed the boundary of health care and social care with the HSE Service Providers.  This resulted in a number of services and the associated expenditure, previously categorised as social care, being reclassified to health care.  Given that health care and social care are often delivered in the same package of services, it has been hard to separate the two types of services and thus the predominant activity (generally health care) has been used to classify the activity and associated expenditure.  This has resulted in the amount of health care expenditure been somewhat over-stated in some areas.

Data revisions since previous publication

The following are a number of revisions undertaken since the publication of data in June 2019:

• For the years 2015 and 2017 there were minor revisions. These were mainly in the household out-of pocket category for inpatient curative and rehabilitative care (HC.13+HC23), and in the long-term care categories. These revisions were due to a processing update.
• In 2017 there was an upward revision of 0.61% to total expenditure, revisions occurred in nearly all categories for HF2 and HF3, largest revisions were in outpatient curative and rehabilitative care (HC.13 +HC23) and inpatient long-term care (HC31). These revisions were due to updated data.
• Refund of medical expenses by revenue. The latest estimates provided by Revenue have been included.     
• Gross Domestic Product (GDP). The GDP figures used in the current publication are consistent with those published in the National Income and Expenditure 2018 and the latest Quarterly National Accounts publication. See National Income and Expenditure - Publication.              
• Modified Gross National Income (GNI*). Modified Gross National Income (GNI*) is equal to Gross National Income at current market prices less the factor income of redomiciled companies, less depreciation on research and development related intellectual property imports and less depreciation on aircraft related to aircraft leasing.

Revised series is available on Statbank in the Database section of the CSO website, using the theme: People and Society\Health\System of Health Accounts, see  Statbank.

Additional tables since previous publication

There are a number of additional tables included since the last publication of data in June 2019:

• HFxFS - The table of the revenues of financing schemes in the chapter titled "Financing Schemes of Health Care Services", this table provides details on the ICHA - FS classification - further detail above. Back years for this table are now available on Statbank. 
• First estimates are now available for 2019, three tables are provided HFxHC, HPxHC and HPxHF. These tables are available in the chapter "Provisional Estimates for 2019", further details below. 

First Estimates for 2019

The total SHA expenditure by the HSE was made available to the CSO, as this accounts for the majority of health care spending it was used to calculate the first estimates for 2019. The profile of spending across the SHA categories does not vary hugely from year to year; therefore the profile of spending from previous years was used to estimate the spending breakdown for 2019. Estimates on household and voluntary health care payments were trended using the consumer price index and the expenditure profile from previous years. 

Other Relevant CSO publications available:

HSE Funded Dental Treatments

HSE Funded Optical Treatments

HSE Funded Pharmacy Claims 

HSE Funded GP Claims

The Household Budget Survey provides useful information on expenditure on health by households. Household Budget Survey