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).

CODES

DESCRIPTIONS

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.

CODES

DESCRIPTIONS

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.

CODES

DESCRIPTIONS

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.

CODES

DESCRIPTIONS

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.

CODES

DESCRIPTIONS

HP.1

Hospitals

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.

CODES

DESCRIPTIONS

FP.1

Compensation of employees

FP.3

Materials and services used

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.

CODES

DESCRIPTIONS

HC.1

Curative 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).

CODES

DESCRIPTIONS

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.1

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

 

CODES

DESCRIPTIONS

INC.1

First quintile

INC.2

Second quintile

INC.3

Third quintile

INC.4

Fourth quintile

INC.5

Fifth quintile

INC.9

Quintile not specified (n.e.c.)

 

CODES

DESCRIPTIONS

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

 

CODES

DESCRIPTIONS

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

ARMM-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.

CODES

DESCRIPTIONS

HK.1

Gross capital formation

   HK.1.1

   Gross fixed capital formation

      HK.1.1.1

      Infrastructure

      HK.1.1.2

      Machinery and equipment

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 the System of Health Accounts 2011 (PNHA-SHA) measures expenditures for the final consumption of health goods and services. It covers expenditures on activities with the primary purpose of improving, maintaining and preventing the deterioration of health and mitigating the consequences of ill-health of individuals in the Philippines for a given year through the application of qualified health knowledge. 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 expenditures (CHE) and health capital formation are estimated as two separate aggregates of the PNHA-SHA.
     
  3. Health expenditures are classified into 12 schemes. The expenditure classifications under each of the three major dimensions of SHA 2011 are listed as follows:

Financing Dimension

- Financing sources (FS): the revenues of the health financing schemes received or collected through specific contribution mechanisms;
- Institutional units of financing sources (FS.RI): institutional units that provide revenues to health financing schemes (a “Reporting Item” or RI under the FS dimension);
- Financing schemes (HF): components of a country’s health financial system that channel revenues received and use those funds to pay for, or purchase, the activities inside the Health Accounts boundary;
- Financing agents (FA): institutional units that manage health financing schemes

Provision Dimension

- Providers (HP): entities that receive money in exchange for or in anticipation of the provision of the activities inside the health accounts boundary;
- Factors of provision (FP): the types of inputs used in producing the goods and services or activities within the HA boundary;
- Capital formation (HK): the types of assets that health providers acquired during the accounting period and that could be used repeatedly or continuously for more than one year in the production of health services.

Consumption Dimension

- Functions  (HC):  the  types  of  goods  and  services  provided  and  activities performed within the health accounts boundary;
- Beneficiary characteristics: the attributes of those who receive health care goods and services or benefit from health activities – e.g. age/sex (AGE), income quintile
group (INC), disease group (DIS) and region of residence (REG).

  1. There are particular health expenditure items that could not be classified into the given schemes 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 schemes mentioned above are reported and summarized in a series of two-dimensional tables.

Actual estimation of the PNHA-SHA is performed for each 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 expenditures of the PNHA-SHA.

I. National  government  (Department  of Health  and  other  agencies)/  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 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, Budget of Expenditure and Sources of Financing (BESF)

- Department of Health (DOH): Statement of Appropriations, Allotment and Obligations (SAAOB)

Estimation Methodology:

- The adjusted program in the NEP, with detail by activity and by expenditure object is utilized as the basic data for the estimation. Additional detail on pharmaceutical expenditures of the DOH is sourced from their SAAOB.

- Expenditures for all health-related activities 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 expenditures on capital outlays reported in the BESF are used.

Distribution Keys:

- Distribution of hospital expenditures by FP from Tsilaajav (2009) hospital costing study, Sample government hospitals Financial Statements from COA, and DOH et. al (2011) Local Health Accounts case studies or other similar studies

- Distribution of government hospital users by income quintile from the Annual Poverty Indicator Survey (APIS)

- Distribution of the general population by income quintile from the APIS

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

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

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

II. National  government  (DOH  and  other  agencies)/  Foreign-assisted projects (FAPs)

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 of FAPs of other government agencies identified as health-related based on stated purpose.

Source Agency and Publication/ Data Inputs :

- DOH-BIHC: Profile and Status of FAPs

- DBM: BESF

- 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 reported in the DOH Report. Expenditures of health projects reported in the BESF and NEDA Report not found in the DOH Report are also included.

- Data provided in the BESF include the actual annual loan availment and counterpart funding by implementing agency and by project.

- Data provided by NEDA for loans already includes actual loan disbursements/drawdowns for the year (in USD). These are then converted to Philippine Peso (PhP). For grants, the current health expenditures are estimated using the utilization rate for the year applied to the project cost.

III. 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 expenditures (Health, Nutrition and Population Control) are divided by the total expenditures for each level of LGU.

- The expenditures for hospitals, health services (health centers) and general administration for health are estimated using distributions data from the Financial Statements of province, city and municipal governments.

- The distributions of LGU expenditures by type of service from the Financial Statements of LGUs will be updated every 3 years based on a sample of LGUs identified from the baseline year.

Distribution Keys:

- Distribution of hospital expenditures by FP from Tsilaajav (2009) hospital costing study, Sample government hospitals Financial Statements from COA,  and DOH et. al (2011) Local Health Accounts case studies or other similar studies

- Distribution of health center/RHU expenditures by FP from sample rural health units or RHUs and from DOH et. al (2011) Local Health Accounts case studies or other similar studies

- Distribution of government hospital users by income quintile from APIS or other survey

- Distribution of population by income quintile from APIS or other survey

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

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

IV. 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 government, private and lifetime programs (employee vs. employer)

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

- Distribution of PhilHealth claims paid by region from PHIC database

- Distribution of government and private hospital expenditures by FP from Tsilaajav (2009) hospital costing study, Sample government hospitals Financial Statements from COA, and DOH et. al (2011) Local Health Accounts case studies or other similar studies

- Distribution of health center/RHU expenditures by FP from sample rural health units or RHUs and from DOH et. al (2011) Local Health Accounts case studies or other similar studies

- Distribution of PhilHealth members (government workers, enrolled self-employed and private sector workers and other enrollees) by quintile from APIS or other survey.

V. 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 purposes.

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)

- Employees Compensation Commission (ECC): State Insurance Fund: Financial Status Report (annual report)

Estimation Methodology:

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

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

VI. 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.

VII. 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 taken 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 APIS

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

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

VIII. Insurance corporations/Health  maintenance organizations  (HMOs)

Coverage:

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

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; also FS from the Securities and Exchange Commission

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 APIS

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

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

IX. Households

Coverage:

- These are the out-of-pocket expenditures of households for goods and services within the health accounts boundary. In the Family Income and Expenditures 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 expenditures (cash only) derived from the FIES to the HFCE level from the national accounts. HFCE levels were adjusted from the proportion of health expenditure (cash only) to total expenditures for cash only.

- Appropriate adjustments are made to the FIES ratios and the HFCE to ensure comparability in their compositions.

- For non-FIES years, the proportion of health care to total household expenditures is estimated with appropriate estimation procedure.

Distribution Keys:

- Distribution of government and private hospital expenditures by FP from Tsilaajav (2009) hospital costing study, Sample government hospitals Financial Statements from COA, and DOH et. al (2011) Local Health Accounts case studies or other similar studies

- Distribution of private clinic expenditures by FP from Sample private clinics (interview) or, if not available, sample RHUs and DOH et. al (2011) Local Health Accounts case studies or other similar studies

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

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

- Weighted distribution of all health facility users by age/sex from APIS or other survey

- Distribution of total billing of users of government and private hospitals by disease from PHIC 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)

X. 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 expenditures include 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.

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

Coverage:

- These are the expenditures by 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: data on the number of establishments by employment size and by industry group and data on the price index for medical goods and services

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

Estimation Methodology:

- Health expenditures of private corporations are estimated by multiplying the average health expenditure per establishment (2012 data as adjusted for inflation to current year) with the number of firms by employment size and by industrygroup for the current year. Total expenditure is estimated as the sum of all expenditures of private establishments across all industries.

- Average expenditures per establishment will be updated every 6 years.

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

XII. Corporations  (other  than  providers  of  health  care)/Private schools  (student health care)

Coverage:

- These are the expenditures by private schools for in-school medical and dental care of students, consisting basically of salaries and wages of school health personnel and medical drugs and supplies.

Source Agency and Publication/ Data Inputs :

- Department of Education (DepEd) and Commission on Higher Education (CHED): number of private schools by enrollment size

- PSA: price index for medical goods and services

- Average expenditures per school by enrollment size from Racelis (2014) study on private schools health spending

Estimation Methodology:

- Health expenditures of private schools are estimated by multiplying the average health expenditure per school (2012 data as adjusted for inflation to current year) with the number of schools by enrollment size for the current year. Total expenditure is estimated as the sum across all sizes of private schools.

- Average expenditures per schools should be updated every 6 years.

Distribution Keys:

- Distribution of persons attending private school by quintile from APIS or other survey.

- Distribution of persons attending private schools by age and sex group from APIS or other survey

REFERENCES

Department of Health, Philippine Health Insurance Corporation, Capiz Provincial Government, Bukidnon Provincial Government, Makati City Government and the World Bank. Case Studies: Local Health Accounts of Capiz, Bukidnon and Makati City (2011). Paper presented  at the National Health Research Forum held in Manila on November 14, 2011.

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.

Tsilaajav, T. (2009). Costing Study for Selected Hospitals in the Philippines: Final Report. Department of Health and European Community, Technical Assistance to the Health Sector Policy Support Program in the Philippines, March 2009.

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