Technical Notes

Introduction

The System of Health Accounts (SHA) 2011 provides a standard for classifying health expenditures according to three (3) axes: consumption, provision and financing. It gives guidance and methodological support for the compilation of health accounts, which seeks to describe the health care system from an expenditure perspective both for international and national purposes. The SHA 2011 is the current international standard for health accounting (OECD, Eurostat, and WHO 2011) which presents a multi-dimensional approach to analyze the structure of health in a country.

The SHA-based Philippine National Health Accounts (PNHA-SHA) not only provides the Total Health Expenditures (THE) of the country, but it also differentiates between two (2) aggregates of health, namely Current Health Expenditures (CHE) and Health Capital Formation (HK). It consists of a total of 12 tables; 11 tables on CHE, and one (1) on HK. These tables contain 12 health expenditure classifications defined as follows:

Institutional units of financing sources (FSRI): Institutional units that provide revenues to health financing schemes (a “Reporting Item” or RI under the Financing Sources or FS dimension).

CODE

DESCRIPTION

FS.RI.1.1

Government

FS.RI.1.2

Corporations

FS.RI.1.3

Households

FS.RI.1.5

Rest of the world

FS.RI.1.nec

Unspecified institutional units providing revenues to financing schemes (n.e.c.)

Financing sources (FS): The revenues of the health financing schemes received or collected through specific contribution mechanisms.

CODE

DESCRIPTION

FS.1

Transfers from government domestic revenue (allocated to health purposes)

FS.2

Transfers distributed by government from foreign origin

FS.3

Social insurance contributions

FS.5

Voluntary pre-payment

FS.6

Other domestic revenues n.e.c.

Financing schemes (HF): Components of a country’s health financial system that channel revenues received and use those funds to pay for, or purchase health care goods, services, and activities.

CODE

DESCRIPTION

HF.1

Government schemes and compulsory contributory health care financing schemes

HF.2

Voluntary health care payment schemes

HF.3

Household out-of-pocket payment

Financing agents (FA): Institutional units that manage health financing schemes.

CODE

DESCRIPTION

FA.1

General government

FA.2

Insurance corporations

FA.3

Corporations  (Other than insurance corporations)

FA.5

Households

Providers  (HP): Entities that receive money in exchange for or in anticipation of producing the activities inside the health accounts boundary.

CODE

DESCRIPTION

HP.1

Hospitals

HP.2

Mental health and substance abuse facilities

HP.3

Providers of ambulatory health care

HP.4

Providers of ancillary services

HP.5

Retailers and other providers of medical goods

HP.6

Providers of preventive care

HP.7

Providers of health care system administration and financing

HP.nec

Unspecified health care providers (n.e.c.)

Factors of provision (FP): The types of inputs used in producing the goods and services or activities covered by the health accounts boundary.

CODE

DESCRIPTION

FP.1

Compensation of employees

FP.3

Materials and services used

FP.4

Consumption of fixed capital

FP.5

Other items of spending on inputs

FP.nec

Unspecified factors of health care provision (n.e.c.)

Functions (HC): The types of goods and services provided and activities performed within the health accounts boundary.

CODE

DESCRIPTION

HC.1

Curative care

HC.2

Rehabilitative care

HC.4

Ancillary services (non-specified by function)

HC.5

Medical goods (non-specified by function)

HC.6

Preventive care

HC.nec

Governance, and health system and financing administration

Beneficiary characteristics: The attributes of those who receive health care goods and services or benefit from health activities. There are four classifications of characteristics in the PNHA-SHA. These include: disease group (DIS), income quintile group (INC), age/sex group (AGE) and region of residence (REG).

CODE

DESCRIPTION

DIS.1

Infectious and parasitic group

DIS.2

Reproductive health

DIS.3

Nutritional deficiencies

DIS.4

Noncommunicable diseases

DIS.5

Injuries

DIS.6

Non-disease specific

DIS.nec

Other and unspecified diseases/conditions (n.e.c.)

 

CODE

DESCRIPTION

INC.1

First quintile

INC.2

Second quintile

INC.3

Third quintile

INC.4

Fourth quintile

INC.5

Fifth quintile

 

CODE

DESCRIPTION

AGE1

0 Male

AGE2

0 Female

AGE3

1-4 Male

AGE4

1-4 Female

AGE5

5-9 Male

AGE6

5-9 Female

AGE7

10-14 Male

AGE8

10-14 Female

AGE9

15-19 Male

AGE10

15-19 Female

AGE11

20-29 Male

AGE12

20-29 Female

AGE13

30-39 Male

AGE14

30-39 Female

AGE15

40-49 Male

AGE16

40-49 Female

AGE17

50-59 Male

AGE18

50-59 Female

AGE19

60-64 Male

AGE20

60-64 Female

AGE21

65 over Male

AGE22

65 over Female

AGEnec

Age/Sex not specified

 

CODE

DESCRIPTION

REG.1

I-ILOCOS

REG.2

II-CAGAYAN

REG.3

III-CENTRAL LUZON

REG.4

IVA-CALABARZON

REG.5

V-BICOL

REG.6

VI-WESTERN VISAYAS

REG.7

VII-CENTRAL VISAYAS

REG.8

VIII-EASTERN VISAYAS

REG.9

IX-ZAMBOANGA PENINSULA

REG.10

X-NORTHERN MINDA NAO

REG.11

XI- DAVAO REGION

REG.12

XII-SOCCSKSARGEN

REG.13

NCR-NATIONAL CAPITAL REGION

REG.14

CAR-CORDILLERA ADMINISTRATIV E REGION

REG.15

BARMM-BANGSAMORO AUTONOMOUS REGION OF MUSLIM MINDANAO

REG.16

XIII-CARAGA

REG.17

MIMAROPA

REG.99

NATIONWIDE

REG.999

Region not specified

Capital formation (HK): The type of assets that health providers have acquired during the accounting period and that are used repeatedly or continuously for more than one year in the production of health services; memorandum items (HKR) reported under the capital formation account include health research and training.

CODE

DESCRIPTION

HK.1

Gross capital formation

   HK.1.1

   Gross fixed capital formation

      HK.1.1.1

      Infrastructure

      HK.1.1.2

      Machinery and equipment

      HK.1.1.3

      Intellectual Property Products

HKR.4

Research and development in health

HKR.5

Education and training of health personnel

General Methodology

  1. The Philippine National Health Accounts, based on SHA 2011, measures expenditure for the final consumption of health goods and services.  It covers expenditure on activities with the primary purpose of improving, maintaining, and preventing the deterioration of health and mitigating the consequences of ill-health of individuals through the application of qualified health knowledge in the Philippines for a given year.  The health accounts boundary is determined based on the following criteria: (a) primary purpose, (b) use of qualified health knowledge, (c) expenditure for resident persons (spatial boundary), (d) expenditure incurred in a specified year (time boundary), and (e) transacted (produced and paid for).
     
  2. Current health expenditure (CHE) and health capital formation (HK) are estimated as two separate aggregates of the PNHA-SHA.
     
  3. The expenditure classifications under each of the three (3) major health accounting dimensions of SHA 2011 are listed as follows:

Financing Dimension

- Financing sources (FS);
- Institutional units of financing sources (FS.RI);
- Financing schemes (HF); and
- Financing agents (FA).

Provision Dimension

- Providers (HP);
- Factors of provision (FP); and
- Capital formation (HK).

Consumption Dimension

- Functions  (HC); and
- Beneficiary characteristics.

  1. There are particular health expenditure items that could not be classified into the given health accounting dimensions above due to lack of detail in the existing data. The breakdowns of these expenditure items are estimated using percentage distributions referred to as distribution keys.  Distribution keys may be prepared using data from research studies, statistical reports, administrative reports, censuses, household survey tabulations, and other data sources, or either.
     
  2. Health expenditures classified under the health accounting dimensions mentioned above are reported and summarized in a series of two-dimensional tables.

Health expenditure in the PNHA-SHA is compiled by component.  Components generally correspond to financing agents (FA) or subcategories of FAs. The components have been primarily defined to correspond to expenditure core data sets. These are the same core data sources used in the previous version of the PNHA. The succeeding notes describe the coverage, data sources, estimation methods, and distribution keys data sources by component of the health expenditure of the PNHA-SHA.

I. National  government  (Department  of Health) /  Domestic revenue based

Coverage:

- These are the expenditures of national government agencies for health-related activities funded by appropriations, with health activities identified based on agency mandate or activity descriptions.

Source Agency and Publication/ Data Inputs :

- Commission on Audit (COA): Annual Financial Report of the National Government, Annual Financial Report of the Government Owned and/or Controlled Corporations, Financial Statements of the four (4) Specialty Hospitals (i.e., Philippine Heart Center (PHC), Philippine Children’s Medical Center (PCMC), Lung Center of the Philippines (LCP), and National Kidney and Transplant Institute (NKTI))

- Department of Budget and Management (DBM): National Expenditure Program (NEP), Budget of Expenditures and Sources of Financing (BESF)

Estimation Methodology:

- Activities under the DOH in the NEP is scaled up using the ratio between the agency-level obligations incurred stated in the COA-AFR and agency-level programmed expenditures stated in the NEP.

- In the estimation of the national government spending on the four specialty hospitals, the amount of subsidy reported in their individual Statement of Income and Expenditures is used.

- In the estimation of the health capital formation of national government, actual health expenditure on capital outlays reported in the BESF are used.

Distribution Keys:

- Distribution of the general population by income quintile from the Family Income and Expenditure Survey (2015 and 2018)

- Distribution of total billing by disease from PhilHealth database for users of government hospitals

- Distribution of total billing by age/sex from PhilHealth database for users of government hospitals

- Distribution of general population by age/sex from Census of Population and Housing

II. National  government  (Other  Agencies)

Coverage:

- These are the expenditures (loans or grants proceeds) of all FAPs of the DOH and other national government agencies whose mandates are entirely health-related (e.g., Food and Nutrition Research Institute (FNRI), Philippine Council for Health Research and Development (PCHRD), etc.); and expenditures from FAPs of other government agencies identified as health-related based on stated purpose.

Source Agency and Publication/ Data Inputs :

COA: Annual Financial Report of the National Government

- DBM: NEPBESF

Estimation Methodology:

- All health-related activities from identified government agencies in the NEP is scaled up using the ratio between the agency-level obligations incurred stated in the COA-AFR and agency-level programmed expenditure stated in the NEP.

- In the estimation of the national government spending on the four (4) specialty hospitals, the amount of subsidy reported in their individual Statement of Income and Expenditures is used.

- In the estimation of the health capital formation of national government, actual health expenditures on capital outlays reported in the BESF are used.

Distribution Keys:

- Distribution of the general population by income quintile from the Family Income and Expenditure Survey (2015 and 2018)

- Distribution of total billing by disease from PhilHealth database for users of government hospitals

- Distribution of total billing by age/sex from PhilHealth database for users of government hospitals

- Distribution of general population by age/sex from Census of Population and Housing

III. Foreign-assisted projects (FAPs)

Coverage:

- Expenditures (loans or grants proceeds) from all Foreign Assisted Projects of the DOH and other national government agencies whose mandates are entirely health-related.

Source Agency and Publication/ Data Inputs:

- DOH-BIHC: Profile and Status of FAPs

- NEDA: Report of ODA Availments by Implementing Agency

Estimation Methodology:

- Current health expenditures of government on FAPS are estimated using actual expenditures data of projects provided in the DOH Report.  Expenditures for health projects reported in the NEDA Report, not found in the DOH Report, are also included in the estimation subject for validation.

- Data provided by NEDA for loans and grants already includes actual loan disbursements/drawdowns and grants actual utilization rates for the year (in USD). These are then converted to Philippine Peso (PhP) using the average of buying and selling rate from the Bangko Sentral ng Pilipinas (BSP).

IV. Local government

Coverage:

- These are the expenditures of provincial, city, and municipal hospitals, as well as expenditures of local governments for health, nutrition, family planning services, health governance and general administration.

Source Agency and Publication/ Data Inputs :

- COA: Annual Financial Report for Local Government, Financial Statements of LGUs

- DOF: Bureau of Local Government Finance (BLGF), Statement of Receipts and Expenditures by LGU

Estimation Methodology:

- Health expenditures of provinces, cities, and municipalities are estimated by applying the health proportions to the total expenditures of each level of LGUs reported in the COA Annual Report.

- The health proportions are computed using BLGF data.  The health expenditure (Health, Nutrition and Population Control) is divided by the total expenditure for each level of LGU.

- The expenditures for hospitals, health services (health centers), and general administration for health are estimated using distributions detailed data from the BLGF. The detailed information is scaled up to match the estimated health expenditure of LGUs.

Distribution Keys:

- Distribution of the general population by income quintile from the Family Income and Expenditure Survey (2015 and 2018)

- Distribution of total billing by disease for users of government hospitals from PhilHealth database

- Distribution of visits by disease using Field Health Service Information System (FHSIS) data

- Distribution of total billing by age/sex for users of government hospitals from PhilHealth database

- Distribution of population age/sex from Census of Population and Housing

V. Social security agencies/PhilHealth

Coverage:

- These are the benefit payments of PhilHealth and all its other expenditures.

Source Agency and Publication/ Data Inputs :

- PhilHealth: Annual Report, Claims Database Tabulations

Estimation Methodology:

- Detailed tabulations of benefit payments from the Claims Database Data for each type of PhilHealth program are adjusted according to the totals by program reported in the PhilHealth Annual Report.  General administrative and operating costs from the Annual Report are used directly without adjustments.

Distribution Keys:

- Distributions of PhilHealth contributions according to the contribution schemes of the members by PhilHealth programs

- Distributions of PhilHealth contributions according to the contribution schemes of the government, private, and sponsored programs (by institutional type) – one distribution key per program

- Distribution of PhilHealth claims paid by region from PhilHealth database

- Distribution of primary and intermediate inputs from the 2018 Supply and Use Tables (SUT)

VI. Social security agencies / SSS, GSIS (Employees’ Compensation Insurance Fund)

Coverage:

- These are the benefit claims payments from the ECIF of SSS and GSIS that are for medical and rehabilitation services.

Source Agency and Publication/ Data Inputs :

Government Service Insurance System (GSIS): Statement of Claims and Benefits Paid – Employees Compensation Insurance Fund, Optional Life Insurance Business/Hospitalization Insurance Plan, and Pre-Need Business/Family Hospitalization Plus Plan (submission upon the request of PSA)

Social Security System (SSS): Computation of EC Health Expenditures (submission upon the request of PSA)

Estimation Methodology:

- EC benefit claims payments data, specifically the claims for medical and rehabilitation services, from reports provided by GSIS and SSS, are used as reported without adjustments.

Distribution Keys:

- Distribution of the workers by income quintile from the Family Income and Expenditure Survey (2015 and 2018)

- Distribution of ill persons or injured at work by age/sex group from APIS or other survey

VII. Social security agencies/GSIS-government based voluntary insurance

Coverage:

- These are the benefit claims payments from the GSIS optional health insurance plans. Existing optional plans include the Optional Life Insurance Fund/Hospitalization Insurance Plan (HIP) and the Pre-Need Insurance Fund/Family Hospitalization Plus Plan (FHPP).

Source Agency and Publication/ Data Inputs :

- GSIS: Statement of Claims and Benefits Paid – Employees’ Compensation Insurance Fund, Optional Life Insurance Business/Hospitalization Insurance Plan, and Pre-Need Business/Family Hospitalization Plus Plan (submission upon the request of PSA)

Estimation Methodology:

- Data on benefit claims payments of the GSIS-HIP and GSIS-FHPP taken from the submission of the GSIS are used as reported without adjustments.

VIII. Insurance corporations/Life  and non-life insurance corporations

Coverage:

- These are the health benefits payments by both life and non-life insurance companies and the administrative costs attributed with health insurance activities.

Source Agency and Publication/ Data Inputs :

- Insurance Commission (IC): Annual Report, financial data on insurance operations and health benefit payments

Estimation Methodology:

- Expenditures of private insurance companies for health and accident benefit payments are sourced directly from the IC annual report.

- General administration and operating costs of health and accident insurance activities are estimated by multiplying the proportion of health and accident premiums to the total general and other operating expenditures of the same company.

Distribution Keys:

- Distribution of persons covered by private health insurance by quintile from the FIES (2015 and 2018)

- Distribution of benefit claims of the Private Sector Program by disease from PhilHealth database

- Distribution of benefit claims for the Private Sector Program by age/sex from PhilHealth database

IX. Insurance corporations/Health  maintenance organizations  (HMOs)

Coverage:

- Total expenditures of HMOs are provided (a) through the Insurance Commission (IC), (b) through the Association of Health Maintenance Organizations of the Philippines, Inc. (AHMOPI), or the Securities and Exchange Commission (SEC).

Source Agency and Publication/ Data Inputs :

- Insurance Commission (IC): Annual Report on HMOs, health benefits payments and administration costs.

- Association of Health Maintenance Organizations of the Philippines, Inc. (AHMOPI): financial statements (FS) of member HMOs.

- Securities and Exchange Commission (SEC): financial statements (FS) of HMOs

Estimation Methodology:

- Expenditures of HMOs for health benefit payments and for general administration are taken directly from the IC annual report.  If the said report is not available, the health expenditures will be taken from the individual financial statements of HMOs.

Distribution Keys:

- Distribution of persons covered by private health insurance by income quintile from FIES (2015 and 2018)

- Distribution of benefit claims of the Private Sector Program by disease from PhilHealth database

- Distribution of benefit claims for the Private Sector Program by age/sex from PhilHealth database

- Distribution of primary and intermediate inputs from the 2018 Supply and Use Tables (SUT).

X. Households

Coverage:

- These are the out-of-pocket expenditure of households for goods and services within the health accounts boundary.  In the Family Income and Expenditure Survey (FIES), these include the following: medicines, food supplements, other medical products, therapeutic appliances, outpatient medical care, dental care, diagnostic services, and private and public hospital care.

Source Agency and Publication/ Data Inputs :

- Philippine Statistics Authority (PSA): Family Income and Expenditure Survey (FIES), data on the proportion of medical care expenditure to total household expenditure

- PSA: data on household final consumption expenditure (HFCE) from the national accounts

Estimation Methodology:

- The private household out-of-pocket health expenditures are estimated by applying the proportion of health expenditure derived from the FIES to the HFCE level from the national accounts.  HFCE levels were adjusted from the proportion of health expenditure to total expenditures.

- For non-FIES years, household expenditures are estimated by extrapolating the FIES-year estimate with the trend of the HFCE Health less benefits from PHIC, Insurance, and HMOs.

Distribution Keys:

- Distribution of primary and intermediate inputs from the 2018 Supply and Use Tables (SUT).

- Distribution of total billing of users of government and private hospitals by age/sex from PhilHealth database

- Distribution of private clinic users by age/sex from APIS or other survey

- Distribution of total billing of users of government and private hospitals by disease from PhilHealth database

- Distribution of Out-Patient Department (OPD) visits by disease using data from the Hospital Operations and Management Information System or HOMIS (sample hospitals only), or using data from other sources

- Combined distribution of government hospital, private hospital and private clinic expenditures by disease (with the distribution for each health facility weighted by out-of-pocket spending on the facility)

XI. Corporation (other than providers of health care)/Government corporations

Coverage:

- These are the expenditures for health care by the Philippine Charity Sweepstakes Office (PCSO) and the Philippine Amusement and Gaming Corporation (PAGCOR). PCSO health expenditures include those of the Individual Medical Assistance Program (IMAP) and the Charity Clinic Department.  PAGCOR health expenditure includes subsidies for health (individual medical assistance and assistance to hospitals, NGOs and foundations), hospitalization (paid directly to hospitals), medical missions, wheelchairs, medical/laboratory equipment and medicines.

Source Agency and Publication/ Data Inputs :

- COA: Philippine Charity Sweepstakes Office (PCSO) Annual Audit Report

- PCSO: Report of Health Expenditures (issued upon request)

- Philippine Amusement and Gaming Corporation (PAGCOR): Report of Health Expenditures (issued upon request)

Estimation Methodology:

- Data from the reports and submissions of the PCSO and PAGCOR are used as reported without adjustments.

XII. Corporations (other than providers of health care)/Private corporations (employee health care)

Coverage:

- These are the expenditures of private establishments for employee health care through, among others, (a) in-house provision of health care (personnel and other facility costs), (b) in-house provision of drugs and medicines, (c) cost of retained health care providers, and (d) fitness/health programs.

Source Agency and Publication/ Data Inputs :

- PSA: 2018 Supply and Use Tables

- Average expenditures per establishment by employment size and industry group from Racelis (2014) study on private establishments health spending for employees

Estimation Methodology:

- For the benchmark estimate, health expenditures of private corporations are estimated by multiplying the average health expenditure per establishment with the number of firms by employment size and by industry group for the current year. Total expenditure is estimated as the sum of all expenditures of private establishments across all industries.

- For non-benchmark years, the estimates from the benchmark year is extrapolated with the trend of health inputs by industry, derived by multiplying Gross Value Added with the technical Coefficient of Human Health Intermediate inputs in the 2018 SUT.

Distribution Keys:

- Distribution of ill persons or injured at work by income quintile from APIS or other survey

- Distribution of ill persons or injured at work by age/sex group from APIS or other survey

REFERENCES

Racelis, R. H. (2014). “Study to Support Improvement of the Philippine National Health Accounts (PNHA): Update on Expenditures for Employer-Provided Health Care and Private Schools Health Services”, Makati City: Philippine Institute for Development Studies, Discussion Paper Series No. 2014-44, April 2014.

World Health Organization. (2011). “A System of Health Accounts 2011” Edition: 2011 Edition (Vol. 2011). OECD Publishing.

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