National health accounts are a powerful tool to systematically track health spending and inform health policy decision making. This chapter provides background information on “A System of Health Accounts” – the international framework to measure health spending in a comparable way. It introduces the key concepts of this accounting framework which is built around the three axes of health financing, service use and provision of healthcare. Finally, the chapter introduces the rest of this publication.
Best Practice in Institutionalising Health Accounts
Learning from Experiences in 13 OECD Countries
Abstract
Across the OECD, countries dedicate substantial resources to the treatment of diseases and improvement of population health. On average, spending on health represents more than 9% of the Gross Domestic Product (GDP) of an OECD country, or around 15% of its public budget (OECD, 2024[1]). Hence, tracking where these financial resources go and how they are mobilised is vital for informed health policy decision making. To this aim, many countries established “National Health Accounts” (NHA) to regularly monitor and analyse health spending in a national context over the past decades, in some instances stretching already over 50 years or more. Yet, international comparability of the results of these National Health Accounts was initially limited.1
In this context, in 2000 the OECD published “A System of Health Accounts” (SHA) (OECD, 2000[2]) as a standard statistical framework and toolkit, borrowing many concepts from national accounts and built upon a set of commonly agreed boundaries, key classifications and categories for countries to identify and analyse health spending in a systematic and internationally comparable way. In 2003, the World Bank, WHO and USAID developed a NHA Producers Guide with a special application to low- and middle‑income countries (World Bank/WHO/USAID, 2003[3]), which complemented SHA. In 2011, after a four‑year revision process led jointly by the OECD, WHO and Eurostat, the Statistical Office of the European Commission, a revised version of the framework – “A System of Health Accounts 2011 (SHA 2011)” – was released as the universal health accounting standard (OECD/WHO/Eurostat, 2011[4]). Since 2016, the annual collection by OECD, WHO and Eurostat of data on health expenditure and financing – called the Joint Health Accounts Questionnaire (JHAQ) – has been based on SHA 2011, and this framework is now widely applied in OECD countries and beyond.
SHA 2011 defines health expenditure based on a tri‑axial approach covering the dimensions health financing (HF), health services (HC) and health provision (HP) built around the conceptual identity that healthcare goods and services that are consumed need to be both provided and financed. The framework recognises current health expenditure – defined as the final consumption of all healthcare goods and services by a population – as the key aggregate for international comparisons of health spending. It provides clear guidelines on the boundaries of healthcare and further develops the categories of the three core dimensions HF, HC, and HP,2 as well as proposing applications for additional analysis beyond the core framework (Figure 1.1).
Within the core framework, the financing dimension of SHA 2011 is centred around the concept of “financing schemes” – which refer to the body of rules based on which a person obtains access to healthcare. At the highest level of aggregation, these can be distinguished between schemes that rely on compulsory/automatic participation (e.g. schemes where entitlement to healthcare services is based on residence – such as the National Health Service in England, or where access is based on insurance coverage – such as the Social Health Insurance in Germany), and voluntary participation (which includes, for example, voluntary private health insurance and out-of-pocket payments). To allow for a more complete picture on how healthcare is financed in countries, SHA 2011 connects these financing schemes with “financing agents” -the institutional units implementing the financing schemes – and the “revenues of financing schemes”, which refers to the methods by which financing schemes generate the resources to purchase healthcare services. In the extended framework the “provision interface” expands the health provider dimension to also identify capital investments by health providers, the input costs of health providers, and exports for each health provider category. Finally, the “consumption interface” can be extended to take account of patient characteristics such as age and gender or break down health spending by diseases and conditions, either as a whole or for selected healthcare goods and services, such as inpatient and outpatient curative care, long-term care, and pharmaceuticals and other medical goods.
Source: OECD/WHO/Eurostat (2011[4]), A System of Health Accounts: 2011 Edition, https://doi.org/10.1787/9789264116016-en.
While SHA 2011 provides a flexible toolkit for the implementation of health accounts in an international context, a number of countries go beyond the recommendations included in the manual to, for example, provide greater detail on the role played by the different levels of government in both financing and provision, or have also developed a health accounts framework that differs to some extent from SHA 2011 (e.g. in using a different boundary of healthcare). Typically, this is the case where National Health Accounts were established before the publication of the SHA in 2000, and where countries see value to continue using their country-specific NHA framework in addition to implementing SHA 2011 for international comparisons. Countries that currently use country-specific NHA include, for example, Australia, Canada, Germany, France and the United States.
To best serve as a useful framework to track health spending and support evidence‑based decision making, health accounts need to be produced regularly (ideally annually), on a timely basis and in a systematic manner. While this is the case in nearly all OECD countries, the way in which health accounts have been implemented from a methodological perspective, and how the production of health accounts has been institutionalised in a country differs widely – reflecting particular health system characteristics, country-specific priorities but also other considerations. This report provides the first in-depth analysis on the state of institutionalisation of the production of health accounts in 13 OECD countries. The work has been supported by the Ministry of Health of Brazil, which is currently in the process of implementing SHA 2011‑based National Health Accounts in Brazil and would like to learn more on current practices in OECD countries to ensure a successful institutionalisation (Box 1.1). It is expected that the findings of this report will also be of use for other countries that are in the process of institutionalising health accounts or want to revise or refine their current approaches to follow some of best practices that have been identified.
A number of important initiatives in Brazil have produced health spending data over the past two decades but a sustained institutionalisation of the health accounts production process in line with international standards has so far been missing.
The first steps to implement National Health Accounts can be traced back to 2006. At that time, an Interministerial Ordinance was passed to establish a technical committee composed of the Ministry of Health, the Brazilian Institute of Geography and Statistics (IBGE), the National Supplementary Health Agency (ANS), Oswaldo Cruz Foundation (FIOCRUZ), and the Institute of Applied Economic Research (IPEA), which was tasked with producing health accounts based on SHA.
The first output of this collaboration was the publication, in 2008, of the Health Satellite Accounts (HSA) data covering the period 2000‑05 (Ministério da Saúde, Fundação Oswaldo Cruz, 2018[5]). This work was spearheaded by the Brazilian Institute of Geography and Statistics (IBGE) and in fact dated back to 2000. The latest edition published by the IBGE in 2024 covers the time period of 2010‑21 (IBGE, 2024[6]).
In 2018, the first National Health Accounts results based on the SHA 2011 methodology were published. These results covered the years 2010‑14 but were limited to the spending of the most important public financing scheme, the “Sistema Único de Saúde” (SUS) (Ministério da Saúde, Fundação Oswaldo Cruz, 2018[5]). In this report, health expenditure by SUS was allocated to healthcare services (HC) and providers (HP) but spending by all other financing schemes were missing, clearly limiting the applicability of the first National Health Accounts results.
While the initial Interministerial Ordinance was revoked in 2019, the researchers involved in this work continued their collaboration and in 2022, a more developed set of National Health Accounts results were published (Ministério da Saúde, Fundação Oswaldo Cruz, Instituto de Pesquisa Econômica Aplicada, 2022[7]). In this publication, health spending estimates by all identifiable financing schemes (including voluntary health insurance and out-of-pocket payments) were presented for the years 2015 to 2019. These also included a breakdown by healthcare services (HC), although a provider breakdown was still available only for SUS spending. The data were also submitted to the OECD, WHO and Eurostat as part of the international JHAQ data request – the first time Brazil participated in this data collection. Preliminary data for 2020 and 2021 were sent in subsequent years.
Since 2024, there has been renewed interest by the Ministry of Health of Brazil to fully institutionalise the production of health accounts according to SHA 2011 and to ensure that high-quality health spending data can be produced on an annual basis in line with international standards. This work is expected to build on these previous studies but also seeks advice from other stakeholders and international experience from OECD countries.
Source: OECD (2025[8]), Institutionalising Health Accounts in Brazil: A Review of Methods, Data and Policy Relevance, https://doi.org/10.1787/b6d405f9-en.
This rest of the report is structured as follows. Chapter 2 provides an overview of the current state of implementation of health accounts in OECD countries, identifying the key dimensions that countries are able to submit in the annual SHA 2011‑based data collections but also highlighting some initiatives in countries that go beyond the international requirements for the estimation of health expenditure data. Chapter 3 introduces the concepts of health accounts institutionalisation and implementation before comparing and contrasting the current practice regarding the governance of health accounts production, the technical implementation and the strategies to disseminate results and their use across 13 OECD countries. Chapter 4 summarises some of the best practices observed across these countries, highlighting some key considerations when it comes to the implementation and institutionalisation of health accounts.
References
[6] IBGE (ed.) (2024), Conta-satélite de saúde : Brasil : 2010-2021, https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=2102075.
[5] Ministério da Saúde, Fundação Oswaldo Cruz (2018), Contas do SUS na perspectiva da contabilidade internacional: Brasil, 2010-2014, Ministério da Saúde, https://bvsms.saude.gov.br/bvs/publicacoes/contas_SUS_perspectiva_contabilidade_internacional_2010_2014.pdf.
[7] Ministério da Saúde, Fundação Oswaldo Cruz, Instituto de Pesquisa Econômica Aplicada (2022), Contas de saúde na perspectiva da contabilidade internacional : conta SHA para o Brasil, 2015 a 2019, IPEA, https://repositorio.ipea.gov.br/bitstream/11058/11014/4/Contas_de_saude.pdf.
[8] OECD (2025), Institutionalising Health Accounts in Brazil: A Review of Methods, Data and Policy Relevance, OECD Reviews of Health Systems, OECD Publishing, Paris, https://doi.org/10.1787/b6d405f9-en.
[1] OECD (2024), Latest health spending trends: Navigating beyond the recent crises, OECD Publishing, Paris, https://www.oecd.org/en/publications/latest-health-spending-trends_df0bb1ba-en.html.
[2] OECD (2000), A System of Health Accounts, OECD Publishing Paris, https://doi.org/10.1787/9789264181809-en.
[4] OECD/WHO/Eurostat (2011), A System of Health Accounts: 2011 Edition, OECD Publishing, Paris, https://doi.org/10.1787/9789264116016-en.
[3] World Bank/WHO/USAID (2003), Guide to producing national health accounts: with special applications for low-income and middle-income countries, World Health Organization, https://iris.who.int/handle/10665/42711.
← 1. A number of countries have also developed health satellite accounts to monitor the economic impact of the health sector within a country. Health satellite accounts are generally fully embedded into the System of National Accounts and measure the health sector’s contribution to the overall economy in terms of value added, employment or trade flows.
← 2. See Annex A for the categories included in the international SHA 2011‑based data request for these key dimensions.