Best Practice in Institutionalising Health Accounts

Annex C. Overview of country experiences in the institutionalisation of health accounts

The following annex provides a country-by-country summary of experiences regarding the implementation and institutionalisation of health accounts in 13 OECD countries. These are provided in table format following the structure of the WHO framework on institutionalisation of health accounts, including governance, technical implementation, and dissemination and use of data.

See the next pages for the country tables.

Australia

Key aspects of health accounts		Australian’s National Health Accounts uses a national definition and national classifications and categories (for areas of expenditure and sources of funds). NHA results are broken down by state and territory (these jurisdictions are also important data providers). SHA 2011 based tables are populated after publication of NHA data. Related NHA work is allocating health spending to diseases and to population groups (e.g. Indigenous population)
Governance	Mandate & legal	The Australian Institute of Health and Welfare (AIHW) is responsible for producing health accounts. There is no explicit legal mandate to produce health accounts but part of the broader AIHW mandate.
	Organisation and co‑ordination	Data submissions from jurisdictions are governed by the Health Expenditure Advisory Committee, wherein the main data providers are represented, allowing for agreements regarding annual data submission. Additional important data sources include Medicare (MBS) and Pharmaceuticals Benefits Schemes (PBS) as well as hospital data available at AIHW. Most private data is obtained from the Australian Private Hospitals Association (APHA) as well as from health insurance funds on a good-will basis. Data on over-the‑counter medicines is purchased from IQVIA.
	Advice	The Health Expenditure Advisory Committee includes the main stakeholders – from jurisdictions to private hospitals and institutions such as the Independent Health and Aged Care Pricing Authority (IHACPA) – and meets twice a year, overseeing the development of health accounts production including data validation. A technical advisory group, a subgroup of the advisory committee, is consulted for specific methodological issues
Technical implementation	Process timeline	Overall health accounts production is a 1‑year process, with NHA and SHA data being produced in sequence. Data requests sent end of Q4 (t) to jurisdictions, which are asked to submit data by end of Q1 (t+1), with data collected from all data providers by end of Q2 (t+1). After data processing and calculations, NHA data is published by Q4 (t+1) SHA production begins immediately after NHA submission and is finalised by the deadline for international reporting in Q2 (t+2)
	Data processing	Data is generally compiled and processed by AIHW. Jurisdictions return standardised data templates, which are processed further by AIHW. SAS is used to retrieve PBS and MBS data directly and to process Excel tables
	QA mechanisms	AIHW validates data, such as by assessing growth rates and trends. Advisory Committee is an additional instrument for quality control. A “data quality statement” is published with each release.
	Institutionalisation of knowledge	Health expenditure report includes an extensive methodological section which also serves to build up capacity for new staff. Manual of Standard operating procedures for internal staff exists. “Pseudocode” in SAS documents the process for internal staff
Dissemination and use	Dissemination and stakeholder engagement	Health spending data is published annually in two reports: the AIHW flagship report “Australia’s Health”, which covers health in general and includes high-level NHA data, and the detailed “Health Expenditure Australia” report. Publication is accompanied by a press release, and Department of Health has early access to the contents as well as to the report. Data tables are made available on the AIHW website. Following data publication, various requests for additional information are received from stakeholders such as government, academia and the general public
	Recent uses of data	Stakeholders use data regarding topics such as cross-regional comparisons, health system sustainability, and private share of spending
	Feedback mechanisms	A summary of data requests is produced each year to be considered for the following report. The data request system is being upgraded to better understand how the public uses the data. Advisory board provides feedback on future developments

Austria

Key aspects of health accounts		In Austria, health accounts are exclusively produced based on SHA 2011 concepts, definitions and categories. A breakdown of health spending by age and gender is produced every 5 years. Health accounts are produced in close collaboration with National Accounts.
Governance	Mandate & legal	Statistics Austria is responsible for producing health accounts, contracted by the Ministry of Health (MoH). The commissioning of health accounts is based on 3‑year renewable contracts. Commission Regulation (EU) 2021/1901 applies
	Organisation and co‑ordination	The co‑operation between Statistics Austria and data providers is not formalised and does not involve contracts, instead relying on voluntary co‑operation, such as with national accounts, federal state representatives, health service providers, and insurance association. SNA and SHA-based accounts are prepared within the same directorate in Statistics Austria which facilitates co‑operation on many data, for example, private expenditure.
	Advice	A technical advisory board for SHA meets annually. The board includes representatives from major data providers and users such as ministries, research institutes, and social insurance schemes. The health accounts team produces substantial reports as information for the board members. The board’s role has changed over time. Initially, the focus was on discussing methodological issues. It has now become more of a forum to discuss results and the political context. An additional expert group regularly conducts ad hoc peer reviews focusing on the methodology of health accounts as per standard procedure within Statistics Austria.
Technical implementation	Process timeline	Total cycle of health account production is 12 months. Between October and January, public and private data is acquired and processed. In February, SHA results (for year t‑2) are published and the report for the MoH is finalised and submitted to the MoH. The report is submitted to the technical advisory board in March and the data is prepared for submission to international organisations. Estimates for year t‑1 are prepared in April/May and published in June. Additional hospital spending analysis is calculated between July and August and published in September as part of the “target monitoring” obligations. In October, the meeting with the technical advisory board of SHA takes place
	Data processing	Statistics Austria is responsible for processing the data to fit the SHA methodology as data obtained from data providers is not completely aligned with SHA concepts. A combination of bottom-up (mostly public spending via government and financial statements) and top-down (mostly private spending via national accounts) approaches are used in the compilation of health accounts. Excel and SAS are used in the different health accounts data processing steps.
	QA mechanisms	Health accounts production follows Statistics Austria’s quality assurance guidelines. Various “input” data sources have their own QA mechanisms. Consistency checks are carried out between final SHA tables and supplementary forms of SHA expenditure, such as time series.
	Institutionalisation of knowledge	Standard documentation including definitions and methods is publicly available. Interim report, prepared annually for the MOH and advisory board, contains methodological information on calculations and revisions. There is no internal centralised staff manual.
Dissemination and use	Dissemination and stakeholder engagement	Health accounts data is announced and released via press releases, Statistics Austria’s website, social media activities. Short information sheets are produced where the data is briefly presented. MoH receives additional evaluations, for example, for monitoring reforms.
	Recent uses of data	SHA data is used to monitor public expenditure targets as defined by the “target-based governance agreement” between federation, states and social health insurance funds. Austrian Court of Audit uses health spending data for producing audit reports on health topics. Health spending data is often cited in political discussions.
	Feedback mechanisms	Technical advisory board provides feedback regarding potential improvements. Standard documentation concerning methods is subjected to peer review every few years by Statistics Austria advisory board. Statistics Austria maintains close contact with data providers on various issues.

Canada

Key aspects of health accounts		In Canada, National Health Expenditure (NHEX) use its own dimensions (Sectors and Use of funds) in their annual publication. Health spending data is allocated to provinces and territories and age groups. SHA 2011‑based tables can be easily mapped to NHEX classifications and are populated based on the results of the most recent NHEX report.
Governance	Mandate & legal	The Canadian Institute for Health Information (CIHI) is the responsible agency for health accounts production in Canada. CIHI is an independent non-profit organisation created by federal, provincial and territorial governments. CIHI does not have an explicit legal mandate for the production of health accounts, but this can be inferred from the overall mandate of CIHI. Stakeholders perceive value in health accounts data.
	Organisation and co‑ordination	Cooperation with data providers is generally based on “good will” without formalised agreements. Data from provinces (such as audited financial statements) and other government sources is generally publicly available. Co‑operation with private data providers is relative smooth. They see some value in the national health expenditure data and recognise that contributing this work can also be in their own interest.
	Advice	A technical working group which includes technical staff for provincial jurisdictions meets twice a year to discuss technical and methodological health accounts issues. An advisory group meets once a year to primarily discuss health accounts results, dissemination strategies and the wider policy context.
Technical implementation	Process timeline	Total health accounts production cycle is 12‑month (from Dec to Nov) Data acquisition starts in December of year t‑1 and continues in Q1 of year t for the production of the actual spending figures for year t‑2. In Q2 of year t the forecasts for year t‑1 are produced based on government budgets. In Q3 of year t time series trends are analysed in the policy context; year t‑1 estimates are shared with provinces and territories. In Q4 of year t, new data including t‑1 forecasts are published in database and report. Work on SHA 2011 tables based published data in Q4 of year t‑1 takes place in Q1 of year t with data being submitted to OECD by end of March.
	Data processing	Data processing is generally done at CIHI. Data to CIHI is submitted in many different formats from both governments and private sources requiring harmonisation using NHEX/SHA as the frame of reference. The various data processing steps are predominantly done with MS-Excel.
	QA mechanisms	Input data received from provinces is validated by CIHI validates through trend analysis. Provinces have an opportunity to validate health accounts results and forecasts produced by CIHI before publication. For forecasted t‑1 spending, private data provider have the opportunity to compare the CIHI estimates with their industry knowledge.
	Institutionalisation of knowledge	Explanatory notes embedded into Excel files guides staff through the production process. Detail methodological notes are publicly available. No comprehensive internal handbook.
Dissemination and use	Dissemination and stakeholder engagement	Dissemination includes media release, interviews, online products such as data tables and a report, and infographics. Federal and provincial ministries are briefed by CIHI on the data leveraging the perceived neutrality and trust of CIHI as an independent institution.
	Recent uses of data	Health accounts results frequently used in policy discussion including in parliament. Health accounts data informed new policy on public coverage of pharmaceuticals (Pharmacare)
	Feedback mechanisms	Feedback is obtained through expert boards as well as via the CIHI website. NHEX (National Health Expenditure Database) Product Review every 5 years with a consultant to obtain feedback

Chile

Key aspects of health accounts		Chile has maintained the historical production of health satellite accounts (HSA), and the ongoing work of HSA production serves as the basis for the production of SHA 2011‑based health accounts.
Governance	Mandate & legal	Ministry of Health (Department of Health Economics) is responsible for producing health accounts (as well as health satellite accounts) The production of health accounts was initially promoted by an interinstitutional committee including the Health Superintendency, Central Bank, the National Health Fund (FONASA), the Economic Commission for Latin America and the Caribbean (ECLAC), and PAHO based on a 2004 resolution. This resolution is to be updated
	Organisation and co‑ordination	There is no formalised basis for co‑ordination between the health accounts team and data providers. Data collection is based on good-will both for public and private data providers. Data requests to public institutions are sent out via email. They usually provide data in a timely manner due to the long-standing co‑operation and the proven data needs. Obtaining data from private providers is more complex. They are requested on a voluntary basis, typically limited to the macro level data.
	Advice	The interinstitutional committee has been inactive during the pandemic, but it is planned to reinitiate its supervisory role.
Technical implementation	Process timeline	The process of data collection is started 2‑3 months before the new year to anticipate potential delays from data providers. Data is generally submitted by data providers during Q1 (t+1), from which an intermediate database based on HSA is built. HSA accounts are then consolidated into SHA tables in time for submitting to international organisations around Q2.
	Data processing	The MoH processes data shared by institutions, mainly from MoF’s Budget Office, which Budget Item 16 includes budget balances of public health institutions such as Health Superintendency and FONASA. The data transmissions are relatively homogenous. While data holders generally transmit data in a MS-Excel format, data processing in the health accounts team is primarily done using R. The process of mapping HSA-based data with the SHA methodology is highly automatised. Data included in Budget Item 16 is very detailed which allows for a disaggregation of SHA results on regional and municipality level. A variety of IT-tool are used for the different production steps (Excel, R).
	QA mechanisms	The interinstitutional committee has participated in the validation of the HSA and SHA data in the past. Through the committee that will be reactivated the MoH collaborates with MoF, INE, Central Bank, FONASA and other relevant institutions to cross-validate the data.
	Institutionalisation of knowledge	Chile is currently working on preparing calculation logs and technical notes to document different aspects of the process of health account production.
Dissemination and use	Dissemination and stakeholder engagement	Products include SHA information in health economics bulletins, analytical statistical articles, infographics, reports on the web platform https://ies.minsal.gob.cl, as well as more methodological documents and research articles. The products are aimed to cover the entire spectrum from the general public to technical experts.
	Recent uses of data	Health account data were recently used in policy discussion on out-of-pocket spending.
	Feedback mechanisms	The committee is currently the main source of feedback.

Costa Rica

Key aspects of health accounts		Though Costa Rica began its production of health accounts following a HSA methodology, currently health accounts are produced exclusively based on SHA. Since 2018, Costa Rica has been producing disease breakdowns following the WHO’s Health Accounts Production Tool (HAPT) “DIS” classification and is currently working on estimates for 2021‑22.
Governance	Mandate & legal	The Ministry of Health (Health Economics Unit, UECS) is responsible for producing health accounts. There is currently no legal mandate for the production of health accounts in Costa Rica beyond the request from international organisations to receive data. A decree is being drafted that could require data providers to share data with the MoH.
	Organisation and co‑ordination	A total of 50 agencies provide data to the MoH, with the Costa Rican Social Security Fund (CCSS) being the largest one. Others include plans dedicated to staff of public institutions, General Insurance Authority (SUGESE), and the National Insurance Institute (INS). There is no formalised basis for co‑ordination between the health accounts team and data providers. Data collection is based on good-will (the decree mentioned above may change this).
	Advice	The National Health Accounts Council (CONACUSA) – formed by the MoH, the CCSS, the University of Costa Rica, INS, the National Institute of Statistics and Census (INEC), the Ministry of Finance, SUGESE, the Central Bank, and the National Union of Local Governments (UNGL) – originally provided methodological and technical support during the development stage of Costa Rican Health Accounts. Following a period of inactivity the council has been reactivated, though discussions are mostly high-level and policy-oriented in nature.
Technical implementation	Process timeline	Data requests (in a specific format) take place in June‑July for t‑1 data, with smaller institutions having a 1‑month deadline. CCSS is requested to provide data by October. Data provided by CCSS is disaggregated by HC and HP, sent to and treated once more by CCSS, which then sends the final dataset by mid-December. Data from other institutions is adjusted as needed. Between January and March (t+1), the data is further disaggregated by other executive units (such as blood banks). The data is then sent to IHAT for international validation and publication. In December (t+1), the results are published in the MoH website.
	Data processing	Data from CCSS is partially processed, with the MoH applying further disaggregations. The MoH processes, analyses, and estimates the data from the remaining data providers. Data from CCSS is plugged into the WHO’s Health Accounts Production Tool (HAPT) directly, while some data sources require some adjustments carried out in MS Excel. The MoH relies on INEC’s household budget survey (ENIGH) for estimating OOP spending. Data is obtained through various means, including interviews and sharing of data files.
	QA mechanisms	Quality assurance involves checking growth rates for all databases, clarifying potential discrepancies, as well as the international quality checks from the IHAT validation process.
	Institutionalisation of knowledge	The UECS team is currently developing a manual that describes, in detail, the production of health accounts.
Dissemination and use	Dissemination and stakeholder engagement	While annual publication of health account results has not been institutionalised to date, data will be made publicly available via the MoH’s website in December 2025 for year t‑2 and is planned to remain a main feature of the annual health accounts production cycle. Despite this, public authorities have had access to health spending data when requested For COVID‑19 spending, an external communications team was hired to target different audiences.
	Recent uses of data	Health spending data was used to draft the National Health Policy 2023‑33 (for example, spending on curative care).
	Feedback mechanisms	Users may contact the communications department of the MoH for any feedback or questions regarding health accounts.

France

Key aspects of health accounts		France’s national health accounts and SHA-based accounts are produced in series, with NHA being produced before SHA accounts.
Governance	Mandate & legal	The Directorate of Research, Studies, Evaluation and Statistics (DREES) within the Ministry of Health is responsible for producing health accounts. A 1970 decree established the foundation for a health accounts committee also providing the mandate for health accounts work. Commission Regulation (EU) 2021/1901 applies
	Organisation and co‑ordination	DREES is the official statistical service of the Ministry of Health. As such it is part of the official statistical service led by the National Statistical Institute (INSEE), which facilitates data access. No formalised agreements have been signed with data providers and data sharing is based on good will – with the exception of the Bank of France regarding data on private insurance spending. There is only limited reliance on private data providers.
	Advice	Health accounts commission has been established by ministerial decree, which also governs the participation in the commission. The commission meets annually and brings together over 60 participants from around 35 institutions to discuss topics ranging from methodological changes, interpretation of data, and potential improvements to health accounts considered within a wider policy context.
Technical implementation	Process timeline	Total production health account production process is around one year. Data extraction takes place during Q2 of year t. Data is processed and supplemented with additional sources during Q3 of year t, with data published by the end of Q3. SHA 2011 based tables are prepared based on the national publication during Q4 of year t. Supplementary work needed of SHA 2011 takes places during Q1of year t+1
	Data processing	DREES is primarily responsible for data processing, with the aim to become less reliant on partners such as hospitals and CNAM (National Health Insurance Fund) As a result, DREES has a more “micro” view of the data for providers. DREES retrieves data from the main health expenditure database (French National Healthcare Data System) without the need for data transmission. R is the primary tool for data processing across all steps of the production cycle
	QA mechanisms	DREES conducts quality assurance at output level, for example checking the plausibility of growth rates for all spending components. Health accounts committee can also be considered as external instrument to ensure quality.
	Institutionalisation of knowledge	Methods are documented with reliance on experienced staff to train new staff. The focus on automation reduces the reliance on knowledge transmission
Dissemination and use	Dissemination and stakeholder engagement	A substantial health accounts report is published annually (including a methodological component), as well as press release and conference with journalists, infographics, a video and social media content. Flat files are also available. A dedicated team in DREES is responsible for press engagement. Data is presented in the committee to various stakeholders. Briefing with Minister of Health regarding health spending data results and trends.
	Recent uses of data	Directorate of Social Security (DSS) of MOH has requested data to inform reforms. Health accounts data is expected to provide input for the parliamentary process for annual social security spending (PLFSS).
	Feedback mechanisms	Health accounts committee provides feedback. DREES receives feedback from data users on a continuous basis.

Germany

Key aspects of health accounts		Germany’s NHA (GAR) generally follows SHA’s breakdown into functions, providers and financing schemes but categories of the dimensions differ. GAR and SHA-based accounts are produced simultaneously but total aggregate (Current Health Expenditure) is identical. Health Labour Accounts and Disease Accounts are linked to GAR via the German provider classification.
Governance	Mandate & legal	Responsible for producing health accounts is the Health Division with the German Federal Statistical Office (Destatis). The production of health expenditure accounts – is regulated in the Health Expenditure and Personnel Statistics Act – GAPStatG of 2021, the Health Expenditure and Personnel Statistics Ordinance – GAPStatV of 2023, in combination with the Federal Statistics Act (BStatG) of 1987 Commission Regulation (EU) 2021/1901 applies.
	Organisation and co‑ordination	Historically, the co‑operation with data providers was mainly informal and based on “good will”. Health accounts team can leverage on many official statistics collected within Destatis. New decree from 2023 stipulates the data and timeline by which the different data holders have to provide data for the construction of NHA. However, this decree only put the common practice into a legal setting.
	Advice	Methodological changes are discussed ad hoc with the Expert Committee on Statistics in Health and Social Services, which meets regularly with experts, data provider, and MOH.
Technical implementation	Process timeline	Data collection from the various data sources begins towards the end of Q3. Following data acquisition, health spending is split into functions, providers and financing schemes following both the NHA and SHA classifications in separate calculation processes (but which happens simultaneously). NHA data is published at the beginning of Q2 of the following year around the same time as the SHA 2011‑based data submission. After this, additional time needed to calculate and publish the analysis of financing sources (end of Q2).
	Data processing	For the production of NHA, roughly 50 data sources are used from 25 data providers. The process of data collection is standardised, but it is not automated and is instead based on individual data requests (which are submitted in various formats). Destatis is primarily responsible for data processing and the final calculation of health accounts. Most input data are Excel-based submissions; ancillary calculations to construct allocation keys are produced in MS-Excel, health expenditure is calculated with MS-Access, SAS is used to produce final output and the SHA tables.
	QA mechanisms	Each step of the health accounts production process is accompanied by quality testing mechanisms.
	Institutionalisation of knowledge	A method manual addresses methodological aspects of health accounts production
Dissemination and use	Dissemination and stakeholder engagement	Full health expenditure accounts data is published as interactive tables on website of Federal Health Monitoring (GBE) and Destatis. Summarised results of health expenditure accounts are published annually in one or more press releases. Additional analytical pieces published irregularly (can be part of wider health statistics publication) User inquiries including from stakeholders are addressed bilaterally
	Recent uses of data	Health accounts team does not systematically track use of data.
	Feedback mechanisms	The feedback obtained from user inquiries as well as from the expert committee is analysed and incorporated into the health accounts production process

Korea

Key aspects of health accounts		The first national health account (2‑dimensional table by financing source and function) including health expenditures from private sources was published in the mid‑1990s. However, no standardised healthcare accounting methodology existed before the SHA manual was implemented in Korea, which was preferred for purposes of international comparability. Consequently, SHA-based accounts are the only available NHA in Korea.
Governance	Mandate & legal	The production of health accounts in Korea is the joint responsibility of a consortium composed of Yonsei University, the Korea Institute for Health and Social Affairs (KIHASA), the National Health Insurance Service (NHIS), and the Health Insurance Review and Assessment Service (HIRA) and is led by a professor as principal investigator from the lead institution (Yonsei University). The consortium is commissioned to produce health accounts based on annual contracts issued by the Ministry of Health and Welfare. The National Health Accounts statistics were designated as being part of national statistics under the Statistics Act.
	Organisation and co‑ordination	The co‑operation between the various partners in the consortium is formalised. Each consortium partner works independently on its assigned tasks and provides its deliverables to the lead institution where it is validated and further processed. The lead institution is responsible for data acquisition for all data outside of the responsibility of other consortium partners. For data of private health insurance, a co‑operation with the private insurance association has been successfully established.
	Advice	The Korean Health Accounts Forum meets annually and gathers various experts in the area of health expenditure, allowing for discussions on best practices, current issues and technical aspects, as well as contributing to the dissemination of health spending results.
Technical implementation	Process timeline	Annual health accounts production cycle begins in July following the latest OECD Health Statistics (SHA) publication. An annual co‑operation plan is developed among consortium partners to implement the annual work plan, also reflecting on experiences from previous years. Data from both consortium and non-consortium providers (such as public health centres) is then collected and processed. Data acquisition and processing continues until April of the following year, when results for year t‑2 (and revised data if necessary) and for year t‑1 (preliminary data) are submitted to OECD and validated by IHAT. Possible revision of data based on IHAT feedback.
	Data processing	All consortium partners process the data that they required to produce as part of their collaboration independently. Each consortium partner submits its output to the lead institution using a specified format. The lead institution collects and processes data from non-consortium institutions and processes this data. The final processing of data, including calculations and creation of output tables at the lead institution is done using MS-Excel.
	QA mechanisms	Total NHA results are validated against officially announced statistics. Each consortium member has its own quality assurance measures in place. The lead institution validates the work carried out by other consortium members. Korean Health Accounts Forum can also be considered as a quality assurance instrument.
	Institutionalisation of knowledge	Each consortium partner has its own internal methodological manual.
Dissemination and use	Dissemination and stakeholder engagement	A National Health Accounts Report, consisted with the SHA accounts submitted to OECD, is published annually. In-depth analytical pieces are regularly published in Korean and international academic journals. Frequent use of data in media.
	Recent uses of data	A 10‑year health spending forecast is often quoted to highlight the need for curbing spending in the future. Data often mentioned in policy discussions, including on healthcare coverage, financial sustainability, pharmaceutical policies.
	Feedback mechanisms	The Health Accounts forum provides feedback annually

Netherlands

Key aspects of health accounts		In the Netherlands, national health accounts refer to “health and social care expenditure” (which also includes other welfare expenditure such as childcare). National categories differ from SHA 2011 but can be easily mapped. Disease accounts are produced based on health accounts results, but this work is carried out in different agency, the National Institute for Public Health and Environment (RIVM).
Governance	Mandate & legal	 Statistics Netherlands (CBS), the National Statistical Institute, is responsible for producing health accounts.  Commission Regulation (EU) 2021/1901 applies.  No legal mandate otherwise. Health and social care accounts are included in Multi-Annual Statistics Programme.
	Organisation and co‑ordination	 In general, standard co‑operation with data holders is formalised in agreements.  According to the Statistics Netherlands Act, CBS may request necessary data from public registries and some private agencies, including register data for insurance claim data (e.g. Vektis).  Health accounts team relies on a lot of information collected directly from CBS. Some private companies (such as Vektis) are legally mandated to provide certain types of data (e.g. from insurance claims) but are contracted by CBS to provide customised datasets.
	Advice	No formal advisory group but ad hoc expert groups have been formed regarding methodological changes (e.g. to discuss the disaggregation of social and health LTC).
Technical implementation	Process timeline	 Health accounts production is roughly a 6‑month process.  Data progressively becomes available throughout the whole year, with some data produced by CBS and any necessary additional data requested from various data providers, after which data processing begins.  Preliminary results for year t‑2 (including price‑volume split) are shared with national accounts (on Sector Q) in the beginning of Q1 and with international organisations in mid-late Q1. During Q2, estimates for year t‑1 and revisions for years t‑2 and t‑3 are produced, as more data from ministries become available.
	Data processing	 CBS employs a custom R-based software and a SQL-database for producing health accounts.  R code handles both the standardised tables from internal data providers as well as more heterogeneous data from external data providers based on the data structures.  The production of NHA and SHA-based accounts is part of a single process whereby NHA is mapped directly to SHA without further data collection or processing required.  Data sources – of varying degrees of granularity, from provider level to municipality level – are used to allocate to health actors, providers, financing schemes and SHA-based healthcare functions. Tools used in different stages of the production process include MS-Excel, R, Python and (phasing out) SPSS.
	QA mechanisms	 Some quality checks are performed on micro-level data that is used as input for health accounts production (e.g. ensuring there are no negative values). For compiled, macro-level data, quality checks focus on totals and overall consistency
	Institutionalisation of knowledge	 There is no comprehensive internal manual for the entire production process. Knowledge transmission is primarily “learn by doing”, but various methodological notes and records regarding sources, inputs and outputs, and timelines exist.
Dissemination and use	Dissemination and stakeholder engagement	 Two datasets are published, health and social expenditure (NHA) and health expenditure (SHA), as well as analyses, press release, and briefing of ministries and relevant stakeholders. Additional statistical research is provided on an ad hoc basis, in the past commissioned by the CBP Netherlands Bureau of Economic Policy.
	Recent uses of data	Discussion on LTC spending as the Netherlands is the highest LTC spenders based on SHA 2011 data.
	Feedback mechanisms	 CBS has an information service that is contacted frequently; this is used to infer the clarity of presentation of data and metadata. Ad-hoc exchanges take place with the ministry regarding topics such as data gaps.

Spain

Key aspects of health accounts		National health accounts (Statistics on Public Health Spending, EGSP) are compiled with data from the 17 autonomous communities (CAs) using a “bottom-up” approach and compiled by the MoH. They only include public spending. SHA 2011–based accounts are produced centrally using a “top-down” approach -relying on NHA- but also includes private spending and LTC (HC3)
Governance	Mandate & legal	The Ministry of Health (Subdirectorate General of National Health System Services and Compensation Funds) is responsible for the production of health accounts. Health accounts included in the National Statistical Plan (updated every 4 years), which is approved by royal decree and is mandatory in nature. Commission Regulation (EU) 2021/1901 applies.
	Organisation and co‑ordination	Main co‑operation is between MoH and CAs, which provide tables requested by MOH based on the COFOG classification. CAs expected to deliver spending data as per the General Healthcare Law (14/1986). CA spending data is standardised and allows for cross-regional comparison. Part of the information is publicly available (such as from MoF), with “gentlemen’s agreements” governing data transmission for the remaining data providers. Other data providers include the National Statistics Institute (INE), private insurers, insurance providers of civil servants (main one being Muface) as well as other directorates within the MoH.
	Advice	Initially, work on national health accounts was promoted by expert groups led by academics. During the implementation phase of SHA 2011 working parties were set up under the Subdirectorate with co‑operation from INE and the Institute for Senior Citizens and Social Services (IMSERSO) to establish criteria and mechanisms for adapting SHA 2011 methodology. There is currently no steering group advising on the production of health accounts.
Technical implementation	Process timeline	Overall health accounts production cycle is around 5‑6 months. National health accounts are produced first by requesting data from central institutions such as MoH and MoF, with CAs expected to deliver data by 15 November. Following validation, data from CAs is recorded, and EGSP summary data and report is produced and published on the MoH website by 31 March. Following JHAQ request for SHA submission in January, various entities such as INE and relevant MoH subunits are contacted to estimate private spending. SHA 2011 data is submitted to IHAT in late April.
	Data processing	For NHA/EGSP, MOH codifies each health spending agent, which produce their own tables for each CA. Processing is conducted by each CA and collated and validated by the MoH. For SHA-based accounts, top-level spending estimates are disaggregated by MoH using EGSP data for public spending and other sources of information such as household budget surveys (INE provides information on OOP spending at 3‑digit level) for private spending and LTC as well as relevant classifications (functions and providers). Data processing is based on MS-Excel.
	QA mechanisms	For NHA/EGSP, the MoH validates the data submitted by each CA (including growth rates). For SHA-based accounts, final tables are validated with relevant international organisations e.g. OECD including the use of built-in validation tools before submission.
	Institutionalisation of knowledge	Knowledge transfer of health account production is generally conducted from person to person, but some methodological notes exist.
Dissemination and use	Dissemination and stakeholder engagement	Results are published on the MoH website as part of “Health at a glance” (Sanidad en un vistazo) produced by the Subdirectorate of Health Information and including infographics, as well as in two different reports, one for NHA/EGSP, one for SHA (SCS).
	Recent uses of data	EGSP data was used as the basis for an analysis of health spending presented at a conference of the Presidents of the CA (in 2004). MoH carried out a technical collaboration with Ministry of Inclusion and Social Security to estimate potential health spending of Ukrainian refugees. Spending on health as share of GDP is currently under significant political scrutiny.
	Feedback mechanisms	Comments and petitions are directed through the Information Office of the MoH, through the press office, or CAs directly to the Subdirectorate.

Switzerland

Key aspects of health accounts		In Switzerland, the NHA uses the same dimensions (services, providers, financing schemes and sources) as SHA 2011 but with some differences in the applied categories. The National health accounts version and SHA 2011‑based health accounts are produced in parallel.
Governance	Mandate & legal	Health accounts are produced in the Health Division of the Swiss Federal Statistical Office (FSO) Health accounts are part of a Multi-Annual Statistics Programme drawn up in accordance with the Federal Statistics Act.
	Organisation and co‑ordination	Article 23 of the Swiss Federal Law on Compulsory Health Care (LAMal) designates FSO as data collector from insurers, service providers and population to produce statistics. Health accounts can draw on this legal stipulation for data use. Co‑ordination between federal agencies – such as the Federal Social Insurance Office and Federal Financial Administration – is very smooth. Gentlemen’s agreements and contracts govern the data co‑operation with private data providers, with some restrictions regarding the use granular data.
	Advice	No expert or advisory boards currently accompany the production of health accounts.
Technical implementation	Process timeline	Health accounts production is roughly a 6‑month process. Data collection takes place during Q1, culminating in the SHA 2011‑based data submission to IHAT by the end of March. The Swiss NHA version is officially published beginning of Q2. The time between Q2 to Q4 is dedicated to addressing special requests such as producing canton-level data as well as exchanges with IHAT on the validating of SHA 2011‑based data.
	Data processing	Some input data is publicly available, some is received by email from specific providers based on request. Format of data transmission from data providers varies – MS-Excel, PDF, flat files. Level of data processing to be conducted by FSO is dependent on type of data – dental and hospital spending data is already published and therefore processed, while data on government spending on health is granular and requires some adjusting. Coding of transactions into national classification and SHA 2011 is carried out simultaneously in the database. R is used in all steps of data processing.
	QA mechanisms	Data quality checks are performed on output, including comparing growth rates and consistency with data published by a Swiss research institute (KOF), the Federal Office of Public Health (BAG) and other FSO statistics.
	Institutionalisation of knowledge	Data processing codes in R include comments that should guide staff in the production process. A methodological document is being prepared, including a technical document for internal use and a high-level one for external audiences.
Dissemination and use	Dissemination and stakeholder engagement	Health accounts results are published on the FSO website, including interactive tables, press releases, and news mail. No specific outreach strategy is employed other than the FSO channels. Media extracts and disseminates the key takeaways from the press release.
	Recent uses of data	In the current discussions on government participation in financing ambulatory care, non-FSO data have been used. There, the FSO was tasked with reconciling its own data with those employed in the political discussion.
	Feedback mechanisms	Not formalised feedback mechanism but rather ad hoc (e.g. exchange with the Dentists Association to clarify NHA methodology).

United Kingdom

Key aspects of health accounts		Health accounts are produced based on SHA 2011 concepts, classifications and categories for the United Kingdom as a whole. This requires a collection of data from all four administrations (England, Wales, Scotland, Northern Ireland) as health affairs are decentralised.
Governance	Mandate & legal	The Office for National Statistics (ONS) is responsible for the production of health accounts at UK level. Legal mandate through Commission Regulation (EU) was applicable until Brexit, upheld in UK law by interim integration of EC legislation, currently no legal mandate. Health accounts produced due to their perceived value and the reputation risk associated with the non-production vis-à-vis commitments to international organisations. Possible option for health accounts exists to receive official accreditation from the Office for Statistics Regulation (OSR), creating a requirement for data production.
	Organisation and co‑ordination	Goodwill agreements exist between ONS and the four health administrations as well other government departments. Some service‑level agreements (SLAs) are used for private providers. Regarding other providers – such as from an independent business intelligence organisation and the Association of British Insurers (ABI) – data partnership arrangements are used by ONS’ acquisition team to receive data and advice, with SLAs drafted for the more technical aspects.
	Advice	A steering group – based on a written understanding that includes a clear mandate – serves as a platform for presenting and discussing results, methodological questions and as external quality control. It includes both government and non-government stakeholders. Another expert group composed of people from health administrations support in methodological work such as provider- and function-level breakdowns.
Technical implementation	Process timeline	The production of health accounts at UK level takes about 6 months. Process is set up with health administrations including desk templates and processing sheets as well as meetings regarding analysis of breakdowns, starting in November. Data acquisition, as well as data processing, takes place between November and February, including from national accounts and from private data providers. QA of data takes places during March including cross-national comparisons, evaluation of growth rates, and bilateral discussions with data producers. The steering group holds “curiosity sessions” during April before publication of the data.
	Data processing	Key data sources from ONS and HM Treasury can be easily accessed. ONS processes all input data received from private providers. For public spending, HC/HP breakdowns are carried out by national administrations (in the case of Northern Ireland, Scotland, and Wales) and then aligned with a control total calculated by ONS based on data from the Treasury. Data transmission is generally in MS-Excel. Data processing is based in Excel, with some QA being conducted with Python.
	QA mechanisms	Continuous QA process. Each national health administration conducts their own QA. Bilateral meetings between ONS and health administrations regarding growth rates, etc. Meetings with external experts. Triangulation with national accounts and Treasury.
	Institutionalisation of knowledge	In-built methodological notes in Excel templates at each step. Manual that provides overview of timeline, with another manual currently produced regarding health accounts production to avoid impact of “brain drain”.
Dissemination and use	Dissemination and stakeholder engagement	UK Health Accounts bulletin accompanied by reference tables published on ONS website. Ad-hoc analytical articles with cross-country comparisons, which attracts media coverage. Standard ONS media note. Policy briefing produced by Department of Health and Social Care and shared with ministers.
	Recent uses of data	Data used in meeting with NHS England and Office for Health Improvement and Disparities regarding preventive care spending. Health Foundation conducted an analysis on use of private healthcare.
	Feedback mechanisms	Contact details are provided upon each release for providing feedback, ONS website offers the possibility to offer feedback. Feedback may be taken into account in HA revision but is ad hoc.

United States

Key aspects of health accounts		The National Health Expenditure Accounts (NHEA) use national definitions and classification to produce health spending estimates by type of good or service, source of funding and type of sponsor base. NHEA are further broken by individual state and by age and sex (every 5 years). NHEA are mapped to SHA 2011‑based tables after NHEA publication.
Governance	Mandate & legal	The Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS), a federal agency within the Department of Health and Human Services (HHS), is responsible for the production of health accounts in the United States. There is currently no explicit legal requirement for producing health accounts, but a mandate can be derived implicitly through the broad mandate of CMS overall. NHA production provides value in understanding health trends and policy impact, as well as being used for international comparisons. Additionally, various legislative provisions require use of national health expenditure trends to adjust insurance benefit parameters and to evaluate CMS programmes.
	Organisation and co‑ordination	Health spending data is collected and shared between different agencies such as the United States Census Bureau, the Bureau of Economic Analysis, the Bureau of Labor Statistics, the Agency for Healthcare Research and Quality, the Centers for Medicare & Medicaid Services, among others. Data is requested formally and informally between said agencies, while formal arrangements exist with some private data providers (including the purchase of data).
	Advice	There is not a formal advisory board that guides the production of health accounts. Instead, the NHEA undergoes revisions every five years to reassess sources and methods where feedback is requested from a wide range of actors regarding methodology of calculation as well as dissemination practice.
Technical implementation	Process timeline	The cycle of health account production takes approximately 6 months. Data acquisition begins in May with the collection of data from public programmes as well as from other sources before being processed. In November, dissemination material is prepared for release on the CMS website. New data including estimates for year t‑1 are released in December (typically in Health Affairs and on CMS website) Population of SHA 2011‑based tables begins after that (based on the new NHEA tables) with this data being submitted to OECD by the end of March.
	Data processing	The Office of the Actuary is responsible for the calculations needed to produce NHEAs, although some major data inputs are used and need to be thoroughly reviewed and adjusted to fit the NHEA classifications. Tools used in the production process primarily include MS-Excel, but also SAS (for the analysis of large databases) and EViews (as data repository).
	QA mechanisms	Data quality checks are conducted internally by health accounts team members. Data is checked and validated throughout the production process. Every 5 years, a NHEA review is conducted – also to check quality of estimates.
	Institutionalisation of knowledge	There is currently no comprehensive internal handbook, though individual documentations exist covering how each estimate is produced and validated. A publicly available “definitions, sources, and methods” document describes how NHEA are constructed. This can also be useful for new internal staff.
Dissemination and use	Dissemination and stakeholder engagement	All estimates and related materials are published on the CMS website. An analytical article summarising the health spending data – both historically as well as projections – is published in the journal “Health Affairs”, which arranges a media briefing.
	Recent uses of data	The CMS Office of the Actuary does not produce analysis from a policy perspective, when requested, presentations are provided to data users including policy makers, researchers, and the media. Policy makers are one of the main data users, using it for modelling and monitoring spending trends, especially following policy changes or during health emergencies.
	Feedback mechanisms	Feedback is received via the CMS website as well as during press release, conferences and presentations. The comprehensive revisions (every 5 years) are also an opportunity to receive feedback on sources and methods.