National health accounts are a powerful tool to systematically track health spending and inform health policy decision making. This chapter provides some background information on the history of health accounts in OECD countries including the development of the System of Health Accounts as the global health accounting standard. It also introduces the key concepts of this international accounting framework which is built around the three axes of health financing, service use and provision of healthcare. Finally, this chapter discusses the history of health accounts in Brazil over the last decades, including the development of health satellite accounts and the two previous publications using the System of Health Accounts.
Institutionalising Health Accounts in Brazil
A Review of Methods, Data and Policy Relevance
Abstract
Countries can apply a variety of approaches to monitor health spending, ranging from basic budget analysis to the use of more comprehensive and systematic frameworks. In its simplest form, health expenditure tracking may involve monitoring executed budgets and the allocations recorded in the financial systems of central, regional, and municipal governments or public health insurance funds. However, such an approach is limited since it captures only a part of total health spending, as it will exclude what in many countries can be significant private spending on health and, in low-income countries (LICs), the important role of external donors in financing healthcare. Additionally, the standard budget classification systems employed may lack the required level of detail to present a thorough picture of where funds are being sourced and ultimately utilised.
Another option applied in a number of countries has been the use of health satellite accounts (HSA). Generally, these sub-accounts are integrated into the System of National Accounts framework and focus on providing information on the contribution of the health sector in the context of the overall economy, in terms of value added and employment. However, a division into the different payers and a detailed list of the goods and services needed for health sector analysis is generally lacking in HSA.
Finally, since the 1970s, a growing number of countries have been tracking all health spending systematically using sector-specific national health accounts (NHA), with breakdowns of health spending typically simultaneously across the financing, provision and/or activity (or service) dimensions. Countries like Australia, France, the Netherlands or the United States have a long history of producing health spending estimates in this way, in some cases stretching back over half a century or longer.
Since the mid‑1980s, in response to these national efforts, international organisations such as the OECD began systematically collecting and publishing health spending data in a more standardised and internationally comparable manner. This laid the groundwork for the development of A System of Health Accounts (OECD, 2000[1]), published by the OECD in 2000, which set important standards for national health accounts by borrowing many of the concepts from existing economic statistical systems, such as the System of National Accounts. Building on and complementing this initial framework, in 2003 the World Health Organization, the World Bank and the United States Agency for International Development jointly released a guide with specific applications to produce National Health Accounts in low- and middle‑income countries (World Bank/WHO/USAID, 2003[2]).
In 2011, after a four‑year consultation process, the OECD, WHO and the Statistical Office of the European Union (Eurostat), jointly published A System of Health Accounts 2011 (SHA 2011) (OECD/WHO/Eurostat, 2011[3]). Since then, SHA 2011 has become the gold standard for health accounting globally and is widely used in high, medium, and low-income countries to systematically track health spending.
Since 2015, SHA 2011 has served as the methodological base of the health expenditure and financing data collection, jointly managed by OECD, WHO and Eurostat – the “Joint Health Accounts Questionnaire” (JHAQ). In the 2024 data collection round, 50 countries participated in this data collection and submitted detailed data on the health spending across the various dimensions.
2.1.1. A System of Health Accounts 2011
SHA 2011 provides for an internationally applicable definition of overall health expenditure and disaggregated health spending categories. The framework establishes current health expenditure as the key aggregate for international comparisons of health spending. It provides clear guidelines on the inclusion of activities, irrespective of the type of financing or provision, within the boundary of healthcare according to the following criteria:
The primary intent is to improve, maintain, or prevent the deterioration of the health status of individuals, groups of the population, or the resident population.
Qualified medical or healthcare knowledge and skills are needed in carrying out the activity, or it can be executed under the supervision of those with such knowledge.1
Consumption is for final use of healthcare goods and services and there is a transaction, meaning that the provision of goods and services is accompanied by a flow of financial resources or other forms of compensation.
SHA 2011 allocates all health expenditures based on a tri‑axial approach covering the dimensions of healthcare financing (HF), healthcare services (HC) and healthcare provision (HP)2 built around the conceptual identity that healthcare goods and services that are consumed need to be both provided and financed (Figure 2.1). The framework further develops the sub-categories of the three core dimensions HF, HC, and HP, as well as proposing applications for additional analysis beyond the core framework.
At the highest level of aggregation, the financing schemes classification (HF) distinguishes between spending by schemes where coverage is either automatic (e.g. based on residence‑based entitlements such as in the English NHS) or compulsory (e.g. social health insurance schemes as they exist in France or Germany), and schemes where coverage or participation is voluntary, and out-of-pocket payments.
The classification of healthcare services (HC) differentiates between the purposes of care, such as curative, rehabilitative and long-term care, ancillary services, public health and preventive care and administrative services. A distinction based on the mode of provision (e.g. inpatient care and outpatient care) is also made.
The provider classification (HP) comprehensively lists all possible facilities and sectors where healthcare can be delivered to patients, including hospitals, outpatient facilities and even households – in exceptional circumstances. The categories defined in the corresponding SHA 2011 classification are exhaustive, and hence should be applicable to all health systems.
Source: OECD/WHO/Eurostat (2011[3]), A System of Health Accounts: 2011 Edition, https://doi.org/10.1787/9789264116016-en.
The annual JHAQ data request is based on a series of two‑dimensional tables combining the various classifications proposed in the SHA 2011, and nearly all OECD countries are able to submit the HFxHC, HFxHP and HCxHP tables with detailed information of different health spending categories.
Beyond the core SHA accounting framework, the financing interface deserves particular attention This interface clarifies how the various financing schemes (HF) – defined as the “body of rules” through which people obtain healthcare services – mobilise the revenues (FS) necessary to finance these services and which entities – financing agents (FA) – manage and implement the different financing schemes. Figure 2.2 clarifies the relationship between these various financing dimensions. Analysing the composition of revenues for the various financing schemes is especially important to obtain an idea of the overall public share of health spending as it tracks transfers and subsidies to other non-governmental financing schemes. Around three‑quarters of all OECD countries provide data on the distinct types of revenues for their existing financing schemes as part of their annual JHAQ data submission.
Source: Adapted from OECD/WHO/Eurostat (2011[3]), A System of Health Accounts: 2011 Edition, https://doi.org/10.1787/9789264116016-en.
The overriding purpose of health accounts is to provide valuable information for evidence‑based health policy decision-making. First and foremost, the implementation of health accounts on a regular basis can increase transparency and accountability in the health system. By clearly laying out all financing flows in the system, there is greater clarity on how financial resources are mobilised, who manages them, what services they are spent on, and to which providers payments are made. Results of health accounts can provide information on the degree of financial protection against the cost of health and the generosity of the public benefit package, by calculating the share of out-of-pocket spending for various healthcare services. They can also provide an indication of the financial sustainability of health spending, when put into context with broader public finance data. Combined with data on health outcomes, health accounts can serve as an entry point for a discussion on the efficiency in the health sector, either at the macro or more micro level. By considering data on service utilisation, health accounts information can also serve as input to assess equity and accessibility of healthcare services. Overall, health accounts should be perceived as a flexible toolkit and their implementation and scope can be adjusted to serve the country-specific needs; in addition to the core framework set out above, a range of additional applications have been linked with health accounts in a number of countries. Finally, aligning National Health Accounts with the SHA 2011 methodology and guidelines ensures that health spending estimates are internationally comparable.
A number of initiatives in Brazil have produced health spending data over the past two decades but a full institutionalisation of the health accounts production process in line with international standards has so far been missing.
In this context, the production of Health Satellite Accounts (HSA) needs to be mentioned. HSA are closely related to National Health Accounts (based on SHA 2011) but have some important differences and perspectives. While SHA 2011‑based health accounts focus on obtaining detailed data on the consumption of healthcare goods and services and mapping out who finances and provides these services, HSA generally focus more on the productive capacity of the health sector, for example, by identifying the value added of the health sector to the overall economy, the labour force employed by the health sector, as well as trade flows in the healthcare sector. As such, HSA are more closely aligned to the System of National Accounts (SNA).3
The first steps to implement National Health Accounts can be traced back to 2006. At that time, an Interministerial Ordinance (437/2006) was passed to establish a technical committee composed of the Ministry of Health, 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 HSA data covering the period 2000‑05 (Ministério da Saúde, Fiocruz, 2018[4]). This work, dating back to 2000, was spearheaded by the Brazilian Institute of Geography and Statistics (IBGE). More recent HSA estimates are available for the years 2005 to 2021.4 The HSA provides data on production, consumption, income, employment, and foreign trade of healthcare goods and services. For 2019, the HSA found, for example, that the final consumption of healthcare goods and products accounted for 9.6% of the GDP, and that activities of the health sector accounted for 7.8% of the value added and 7.4% of all employment in the Brazilian economy (IBGE, 2022[5]).5
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 spending of the most important public financing scheme, the “Sistema Único de Saúde” (SUS) (Ministério da Saúde, Fiocruz, 2018[4]). 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 this first National Health Accounts pilot.
While the initial Interministerial Ordinance was revoked in 2019, the researchers involved in this work continued their collaboration and in 2022, a set of more developed National Health Accounts results were published (Brasil. Ministério da Saúde, 2022[6]). In this publication, health spending by all identifiable financing schemes (including voluntary health insurance and out-of-pocket payments) were presented for the years 2015 to 2019. This also included a breakdown by healthcare services (HC), although a provider breakdown was still available only for SUS spending. This data was 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. The data was also used to assess the performance of the Brazilian health system as part of the OECD Health System Review: Brazil 2021 (OECD, 2021[7]). Preliminary data for 2020 and 2021 were also submitted in subsequent years.
Since 2024, there has been renewed interest by the Ministry of Health of Brazil resulting in the establishment of a multidisciplinary team specifically 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 the existing pilot studies carried out in country but also seeks advice from other stakeholder and international experience from the OECD.
References
[6] Brasil. Ministério da Saúde (2022), Contas de saúde na perspectiva da contabilidade internacional : conta SHA para o Brasil, 2015 a 2019, Ipea, https://doi.org/10.38116/978-65-5635-028-8.
[5] IBGE (ed.) (2022), Conta-satélite de saúde : Brasil : 2010-2019, https://biblioteca.ibge.gov.br/visualizacao/livros/liv101928_informativo.pdf.
[4] Ministério da Saúde, Fiocruz (2018), Contas do SUS na perspectiva da contabilidade internacional: Brasil, 2010-2014, Ministério da Saúde; Fiocruz, https://bvsms.saude.gov.br/bvs/publicacoes/contas_SUS_perspectiva_contabilidade_internacional_2010_2014.pdf.
[7] OECD (2021), OECD Reviews of Health Systems: Brazil 2021, OECD Reviews of Health Systems, OECD Publishing, Paris, https://doi.org/10.1787/146d0dea-en.
[1] OECD (2000), A System of Health Accounts, OECD Publishing, Paris, https://doi.org/10.1787/9789264181809-en.
[3] OECD/WHO/Eurostat (2011), A System of Health Accounts: 2011 Edition, OECD Publishing, Paris, https://doi.org/10.1787/9789264116016-en.
[2] 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. Or the activity refers to the governance, administration and financing of the health system.
← 2. See Annex A for the categories included in the international SHA 2011‑based data request for these key dimensions.
← 3. However, in a number of countries SHA 2011‑based NHA are also considered as satellite accounts due to their integration into the System of National Accounts, in particular when final consumption expenditure is closely aligned with current health expenditure.
← 4. It should be noted that due to regular updates in the methodology of Brazil’s System of National Accounts this does not comprise a single time series. The last edition of HSA covers the period of 2010-2021, for which there is a compatible time series for production and consumption of health products and value added in the production activities of those products.
← 5. IBGE has subsequently published the 2021 HSA at: https://www.ibge.gov.br/estatisticas/economicas/contas-nacionais/9056-conta-satelite-de-saude.html?=&t=publicacoes.