Best Practice in Institutionalising Health Accounts

2. Implementation of health accounts in OECD countries

Abstract

Nearly all OECD countries have meanwhile implemented “A System of Health Accounts” and produce internationally comparable data on health expenditure and financing on an annual basis. This chapter provides an overview on the status of health accounts implementation across OECD countries, in particular the various dimensions reported. It also highlights examples from countries that have gone beyond the standard reporting of health expenditure and financing data for international purposes and have implemented additional dimensions for national analysis. This can refer to a breakdown of health spending on a subnational level or based on beneficiary characteristics, such as age, gender or disease.

This chapter provides a brief overview of the extent or the degree to which health accounts are currently implemented across OECD countries, which is important background information to better understand the following comparison of how health accounts are institutionalised. This assessment is based on the annual reporting of data on health expenditure and financing to the OECD (as part of the JHAQ) and additional information available to the OECD Secretariat as of 2024.1 The status of implementation can be seen in Table 2.1. With the exception of New Zealand, all OECD countries currently submit some data on health spending and financing based on the SHA 2011 core classifications: health financing (HF), healthcare services (HC) and health providers (HP).2 This suggests that most OECD countries have (at least partially) implemented the definitions, classification and health spending categories recommended in the SHA 2011 manual to track health expenditure for international purposes. Beyond providing data for the core framework of SHA 2011, more than three out of four OECD countries are also able to identify the various revenues of financing schemes (FS), while some information on capital investment in the health sector (HK) is reported by around two out of three OECD countries. Only a handful of countries provide information on input costs of health providers (FP).3

Yet, Table 2.1 hides important differences in the level of reporting detail. While some countries are able to report data for each of the classifications for most or all proposed categories, others limit their reporting to a more aggregate level – thereby reducing the functionality of health accounts to some extent. Belgium and Estonia, for example, are countries with very detailed reporting on healthcare services (HC). On the other hand, the level of reporting by Italy or Portugal for the functional categories is more limited – though still complying with the reporting requirements of the European Commission.4

While the quality of reporting and its comprehensiveness has steadily improved across OECD countries over the last decade for the three core dimensions of SHA 2011 (HC, HP, HF), some important reporting issues and data gaps remain. For example, various countries struggle to distinguish between generalist and specialist care in their outpatient sector spending data, which is important information for the estimation of primary healthcare spending. There continue to remain boundary issues with the identification of the social component of long-term care and in several cases some elements of social long-term care are included under health long-term care. Finally, the COVID‑19 pandemic has revealed that not all countries are able to fully account for preventive care spending and may misallocate some preventive activity to other functions or outside of health.

Beyond the standard data reporting on health expenditure and financing for international comparisons, a number of countries provide more detail in their health accounts that are deemed useful for national analysis or include categories that go beyond the SHA 2011 boundaries.5 For example:

• Australia publishes its National Health Expenditure data based on Financial Years (July to June) using a national definition of health expenditure (which includes research and investments) and uses national classifications for financing, services and providers (AIHW, 2024[1]). Within the reporting of healthcare services, they include primary healthcare as a separate category;6 for providers, they publish spending on private and public hospitals separately. Under the financing dimension, they distinguish between funding by the Australian federal government and state and territory governments. They also provide a break-down of sub-national health spending by states and territories for the resident population. In their annual publication, a time series of health spending, both in current and constant prices is displayed. Moreover, additional analysis allows to identify health spending from indigenous people and compare it to the non-indigenous population.

• In its national health expenditure publication National health expenditure trends, Canada distinguishes public spending on health for the three levels of government (i.e. federal, provincial/territorial, municipal) in addition to spending by social security (CIHI, 2024[2]). The Canadian aggregate measure of public and private health spending also covers capital spending and is broken down by province/territory and various health spending categories. Provincial and territorial spending is additionally broken down by age (20 groups) and sex. Canada also uses a health-specific deflator to provide health expenditure estimates in both current and constant prices.

• For their detailed national analyses, France deviates from the SHA 2011 definition and uses a narrower aggregate called “Consommation de soins et bien medicaux” (referring to curative and rehabilitative care, ancillary services and medical goods) and applies an alternative classification of healthcare services and providers, for example separating private and public hospitals and identifying ambulatory providers on a more granular level (DREES, 2024[3]). They also describe health spending trends in both current constant prices using health-specific deflators to decompose growth in volumes and prices.

• While the notion of health spending for national analysis in Germany is identical to that set out in SHA 2011, the functional and financing classifications differ (GBE BUND, 2024[4]). For the types of services, Germany sees a need to distinguish, for example, spending on medical services (provided by doctors) from spending on nursing care (provided by nurses or nursing aides) and to separately identify costs for room and board (in hospitals or nursing homes). In their financing classification, there is a need to distinguish the different types of social insurance schemes that provide health services.7 Germany also regularly links their national health accounts to their disease accounts – for each health provider they allocate health spending to age groups, gender and diseases (based on ICD‑10). The country also produces health labour accounts on an annual basis – for each health provider they identify the health (and other) workforce, broken down by profession, age groups, gender, and employment type.

Table 2.1. State of implementation of SHA 2011 and health accounts in the OECD

	JHAQ submission includes the following dimensions						Additional implementation
	HF	HC	HP	FS	FP	HK
Australia	X	X	X	X		X	National version of Health Accounts; regional breakdown, disease accounts, specific population groups
Austria	X	X	X			X	Public current health expenditure for State Health Funds financed hospitals by federal state; Breakdown by age and gender (every 5 years)
Belgium	X	X	X	X
Canada	X	X	X	X	X	X	National version of Health Accounts; regional breakdown, breakdown by age
Chile	X	X	X	X			Health Satellite Accounts, regional breakdown
Colombia *	X			X
Costa Rica	X	X	X	X	X	X	Breakdown by disease
Czechia	X	X	X	X		X
Denmark	X	X	X	X		X
Estonia	X	X	X	X
Finland	X	X	X	X		X
France	X	X	X				National version of Health Accounts
Germany	X	X	X	X			National version of Health Accounts; breakdown by age, gender and diseases; Health Labour Accounts linked to National Health Accounts
Greece	X	X	X			X
Hungary	X	X	X	X		X
Iceland	X	X	X	X	X	X
Ireland	X	X	X	X		X
Israel	X	X	X	X		X
Italy	X	X	X
Japan	X	X	X	X
Korea	X	X	X	X		X	Regional breakdown; breakdown by age, gender and disease
Latvia	X	X	X	X		X
Lithuania	X	X	X	X
Luxembourg	X	X	X	X
Mexico	X	X	X	X		X
Netherlands	X	X	X	X			Health expenditure part of “Health and care accounts” which also includes social work and childcare.
New Zealand
Norway	X	X	X	X		X
Poland	X	X	X	X		X
Portugal	X	X	X
Slovak Republic	X	X	X	X
Slovenia	X	X	X	X		X
Spain	X	X	X	X		X	National version of Health Accounts based on public health spending for the 17 regions
Sweden	X	X	X	X		X
Switzerland	X	X	X	X			National version of Health Accounts; breakdown by age, gender and region
Türkiye *	X		X	X		X
United Kingdom	X	X	X	X		X
United States	X	X	X	X	X	X	National version of Health Accounts; regional breakdown

Note: Assessment based on the latest JHAQ submission rounds. HF refers to health financing schemes, HC to healthcare functions, HP to health providers, FS to revenues of financing schemes, FP to factors of provision, HK to Gross Fixed Capital Formation in SHA 2011. * Colombia and Türkiye are not yet fully compliant with SHA 2011 reporting since some dimensions are still missing. Additional implementation only added for countries reviewed in this report.

Source: OECD Health Statistics 2024 and information available at the Secretariat.

• In the United States, the National Health Expenditure includes two financing breakdowns (by “source of funding” and “type of sponsor”) and allocates health spending to various types of expenditure – based on a mix of services and providers (CMS, 2024[5]). The scope of National Health Expenditure in the United States is wider than under SHA 2011 and also includes spending on research, as well as on structures and equipment. The accounts provide a breakdown of health expenditure by region and on a state‑level. Interestingly, this geographic breakdown is carried out twice, based on residency of population consuming healthcare services and the location of health providers. Additionally, a breakdown of spending by age (for five age groups) and sex is calculated regularly (but not annually) on a national level. Health spending is published in current and constant prices.

The overview Table 2.1 and the country examples demonstrate two things: (i) nearly all OECD countries see value in estimating data on health spending and financing on a regular basis and across many dimensions based on SHA 2011; and (ii) while the international JHAQ data collection provides a good entry point for the analysis of health expenditure and financing data and their international comparison, countries may have identified additional needs for health accounts data that go beyond what is currently collected by international organisations. This can lead countries to deviate to a certain degree from the standard (international) classifications, to obtain, for example, subnational data or to produce an age/sex breakdown of health expenditure. Decomposing health spending trends in current prices into price and volume components to better understand the drivers of health spending also appears to be of interest to several countries, particularly in times of high and diverging trends in prices in the health sector and the economy more broadly (Mueller et al., 2025[6]).

References

[1] AIHW (2024), Health expenditure Australia 2022–23 - web report, Australian Institute of Health and Welfare, https://www.aihw.gov.au/getmedia/78531cd2-900a-43b6-97b1-8072b441de6c/health-expenditure-australia-2022-23.pdf?v=20241120164118&inline=true (accessed on 10 January 2025).

[2] CIHI (2024), National health expenditure trends, Canadian Institute for Health Information, https://www.cihi.ca/en/national-health-expenditure-trends (accessed on 29 November 2024).

[5] CMS (2024), National Health Expenditure Data, https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data (accessed on 29 November  2024).

[3] DREES (2024), Les dépenses de santé en 2023 - Résultats des comptes de la santé, DREES, https://drees.solidarites-sante.gouv.fr/sites/default/files/2024-11/CNS24.pdf.

[4] GBE BUND (2024), “Gesundheitsberichterstattung des Bundes”, Gesundheitsausgaben in Deutschland, https://www.gbe-bund.de/gbe/ (accessed on 28 November 2024).

[6] Mueller, M. et al. (2025), “Analyse de la croissance des dépenses de santé en France et en Allemagne - décomposition des effet de prix et de volume”, Documents de travail de l’OCDE sur la santé, Vol. 174, https://doi.org/10.1787/a1cb3bba-fr.

Notes

← 1.  In some instances, the national reporting may however be more detailed than what is submitted to the OECD. Annex A displays the level of detail requested from countries for the three core classifications HF, HC and HP for the international JHAQ requests.

← 2.  Colombia is currently lacking health spending data for services and providers, Türkiye is not providing data for health services.

← 3.  While the data collection on input costs is part of JHAQ, the reporting has not featured as a priority to date from the International Health Accounts Team and this is reflected in the low submission rate from countries.

← 4.  See Section 3.2 for more information on the SHA reporting requirements based on European legislation.

← 5.  Annex B provides an overview of the national classifications/categories used by countries if they deviate from SHA 2011.

← 6.  Primary healthcare is not a category within the SHA 2011 framework although both OECD and WHO estimate spending on PHC based on the JHAQ submission using different approaches.

← 7.  Germany has five “pillars” of social security: health insurance, accident insurance, pension insurance, long-term care insurance and unemployment insurance (each implemented by a number of different insurance funds) which all finance some healthcare services (as defined in SHA) to differing degrees.