2003 Multi-Beneficiary Programme for Statistical Co-operation with the Phare Countries FINAL REPORT ESTAT

Transcription

1 2003 Multi-Beneficiary Programme for Statistical Co-operation with the Phare Countries FINAL REPORT ESTAT Volume 6 HEALTH LABOUR ACCOUNTS January 2006 This final report was prepared by ICON-INSTITUT in co-operation with the Eurostat Project Leader and Experts

2 Final report TABLE OF CONTENTS Page Page 2 1 Structure of the final report 4 2 Executive summary 5 3 Institutional Setting, main contact persons 8 4 Background of the project Main Objectives Basic documents 11 5 Project Implementation Meetings Missions (per country) Trainings if any Work phases Results achieved (per country) Results: All countries 37 6 Recommendations for future steps to be undertaken in the Project Area by Beneficiary Country by Eurostat 50 7 Conclusions 52 8 Annexes (not included) 54 2

3 Final Report 3

4 Final report 1 Structure of the final report Volume 6: Health Labour Accounts 4

5 Final Report 2 Executive summary The project on health labour accounts is part of a larger PHARE project which includes also other statistical domains covered by Eurostats regular programmes. The project is financed under the special PHARE programme of the European Commission for new member states and candidate countries (beneficiary countries), budget of the year The project aims at assisting beneficiary countries with the adaptations of the national statistics required for regular reporting to Eurostat according to the agreed standards and technical specifications. The aim of the project was the development of necessary elements for a later implementation and sustainability of in beneficiary countries. The following countries participated in the project: Bulgaria, Czech Republic, Hungary, Slovak Republic, Slovenia, Estonia, Latvia, Lithuania, and Romania. The project was coordinated with grant contracts between Eurostat and the individual countries on the same subject. For almost all countries these contracts includes the development of prototype data, with the PHARE project supporting this. In the present project the emphasis were on three main parts The evaluation of data sources available for Preparation for compilation of data in comprehensive multi-source data systems such as Assist countries on an initial collection of sample data by Eurostat (under grant agreement between Eurostat and the individual countries) 5

6 Final report For building up the end goals stepwise, the work was structured in phases. The project was divided into three major parts and steps. 1. methodology To ensure a common starting point the basic methodology was repeated, and a framework model for development was created. The framework model was combined with a suggestion for a stepwise approach towards, including a priority in the work with. 2. Data sources and meta data The data source inventory from the PHARE 2002 project was used as a starting point. Countries combined the data sources with a detailed meta data description related to. These meta data working tables were linked to the stepwise approach towards. 3. prototype data Experts gave advice to countries on initial collection of sample data as part of grant agreements between Eurostat and PHARE countries. For a number of countries complete or partly s was developed during the project. This was done building on the methodological knowledge in countries and the knowledge on data sources through the meta data descriptions. It can be concluded, that all participating countries fulfilled the content of the PHARE project. For all countries a number of relevant data sources was pointed out, and the quality of these data sources were examined. Experts gave countries advice on adjustments of existing data sources or need on development of new data sources. All countries described the status and work on with the mission checklist and data sources in the meta data working tables developed within the project. In respect to meta data working tables a variation of tables were filled out across countries. The results are summarised in the table below. Summary of results with respect to metadata documentation (PHARE project) and prototype data availability (countries outputs corrected and submitted to ICON experts on ) Checklist Meta data working tables Prototype data Bulgaria Filled in 5 out of 8 tables Not available Czech Republic Filled in 5 out of 8 tables Available Estonia Filled in 5 out of 8 tables Not available Hungary Filled in 5 out of 8 tables Not available 6

7 Final Report Latvia Filled in 5 out of 8 tables Not available Lithuania Filled in 7 out of 8 tables Available Romania Filled in 6 out of 8 tables Available (only for total employment) Slovak Republic Filled in 5 out of 8 tables Not applicable Slovenia Filled in 6 out of 8 tables Available For a number of countries complete or partly s was developed during the timeframe of the project. The development was done according to grant contracts between countries and Eurostat, and as such determined by these contracts. The further development beyond the timeframe of the PHARE project and reporting on the contracts are done to Eurostat directly. The key recommendations from experts to beneficiary countries, is as a general point to continue the work on. The further development of and in particular the exploration and review of data sources and the necessary adaptations of these sources should be part of the structural annual statistical programmes. Further more such efforts could best be coordinated with the work on SHA. The project has shown great advantages from coordinating the work on SHA and, since these systems creates synergies on both the methodological side, and in the work on data sources and statistics. The key recommendations of the expert to Eurostat are for continued support to development of. This implies both methodological and statistical support to countries with among other things maintaining forum for the exchange of knowledge and experience between countries. Eurostat should consider developing actual guidelines for. The guidelines should be consistent with SHA. The methodological development and guidelines on this basis of this, is necessary for a development of harmonised statistics in EU. The results within this project in terms of the framework model and stepwise approach towards can be seen as early steps to a developed methodology. In order to create the necessary human resource basis in Europe for SHA and, regular training is needed. However because of the current shortage of qualified trainers in SHA and a programme for training of trainers should be given serious consideration. 7

8 Final report 3 Institutional Setting, main contact persons The project experts were Ms Dorota KAWIORSKA, Mr Jacques BONTE and Mr Morten HJULSAGER (project manager). Mrs. Lorena von Jonquières was the implementation manager at ICON Institut Public Sector GmbH. In the first phase of the project, content and project plan with milestones were discussed with Eurostat. This was done to ensure the operationalisation of the project in line with the intensions of Eurostat. Discussions were carried out with the Health Unit in Eurostat. Following this initial discussion the experts had regular exchange of information with the subject matter specialists of Eurostat. The main points in this information exchange related to the aims and objectives of the project, the agendas of meetings, the recent developments in Eurostat and its related projects, leading to adaptations on the practical implementation of the project in order to yield more adequate and practical results. The starting point in the relation with beneficiary countries was to make official relations through the National Statistical Institutes (NSI) with the national authorities and units responsible for. In many countries the NSI is responsible for both SHA and. However, in several countries other institutions are deeply involved and in some countries responsible. These institutions are mainly Public Health Institutes of the state or statistical units in the ministries of health. The next activity when launching the project was to find the qualified contact persons. The person attending the kick off meeting of the project held in Sofia April 2005, became the contact person for the experts during the implementation of the project. A list of contact persons are found in the annex. Later in the project contact persons were assisted by staff members and colleagues of the NSI and in some cases of other government agencies responsible for specific components of manpower statistics. Building on the efforts of and improvement since the previous PHARE projects on health statistics (2001 and 2002) from the start of the project it was stressed by the experts that for the practical implementation of the project a close collaboration between all those involved at national level was encouraged. This fostered a synergy of efforts and knowledge and was a stimulus to continue practical working relations established through the earlier PHARE projects. At the time of project start the PHARE 2002 project on health care statistics (SHA) was still running, and with the close relation between SHA and the SHA- and -projects were coordinated. Practically in terms of meetings, person wise in terms of the overlap of key persons in the two projects, and finally content wise in terms of the related subject. 8

9 Final Report 4 Background of the project Statistics on public health and supporting projects of Eurostat, as agreed by the Statistical Programme Committee (SPC) and reflected in the programmes of the EU are arranged in three domains of statistics Statistics on causes of death (COD) Health and health related interview survey data, disability interview surveys (HIS/DIS) and diagnoses related morbidity data Statistics on health care (CARE) belong in that organisation to CARE. The domain of CARE covers several statistics for which substantial methodological development is required. The purpose of the system is to develop coherent and comparable information on a complex set of topics, e.g. on expenditures of the health care sector and its financing, persons working in the health care sector and on the utility of the health care sector. The statistics are to a large extend not directly comparable at the international level mainly due to differences in the organization of national health care systems. At the national level many data is not available and if available not at a central place or not in a systematic statistically sound way. Thus comparison can only be achieved by ex-post harmonization. Work on health accounts has led to the establishment of a manual for a system of health accounts ( A System of Health Accounts, OECD 2000). It is a common framework for consistently comprehensively dealing with all perspectives of health care provisions. It sets the framework for health care expenditures, which are the financial component of SHA. Human resources in health care are the most important production factor in the sector. Health Labour Accounts () define Human Resources in Health Care (HCHR) in the SHA context. It was agreed by the Statistical Programme Committee (SPC) that in the framework of the European health statistics system the SHA manual is the backbone for health accounts at European level. Application of the SHA manual in member states (15 MS) started in 2000 and later. The first collection of SHA data by Eurostat from all EU member states will take place in the beginning of Eurostat has for a period of time collected manpower statistics from member states. Within recent years, it has as a pilot exercise, been requested from member states to deliver manpower divided by the ICHA-HP categories of the SHA-manual. 9

10 Final report 4.1 Main Objectives The core objective of PHARE projects in general is to support new member states and candidate countries in order to be able to report regularly to Eurostat according to the EU standards. In the case of CARE statistics much emphasis is on making the national statistics compliant with the EU standards especially because of the rapid organisational reforms. This involves also evaluating and setting up country-specific statistical sources and preparing countries for compiling data in comprehensive multisource data systems, such as SHA and. Under the PHARE Programme 2001 a project component on public health statistics provides the basis for the present project. From this 2001 project one of the main recommendations was to give high priority to the development of SHA. The development of should follow afterwards once that the SHA is operational in member states, since should built on the SHA framework and standards. Under the PHARE 2002 project SHA was implemented with the result of prototype data in all PHARE countries. Building upon the results of the previous PHARE projects, the emphasis in the present project is on Identify and quality-asses existing data sources on manpower active in the public and private provision of health care Prepare PHARE countries for compiling data in comprehensive multi-source data systems such as with the objective of setting up a prototype system Assist countries in respect to grant agreement between Eurostat and PHARE countries The expected results of the project are 1. A detailed evaluation of data sources available for, including recommendations towards necessary improvement in order to meet requirements 2. A detailed evaluation of and preparation for compilation of data in comprehensive multi-source data systems, 3. Assist countries on an initial collection of sample data by Eurostat (under grant agreement between Eurostat and PHARE countries), with focus on building a prototype statistical system for 10

11 Final Report 4.2 Basic documents Background documents for the project were: The European Union documents on five year and annual programmes (Eurostat work programmes) Working documents of Eurostat, in particular on health care statistics, e.g. on the framework for health care statistics Disseminated statistics of Eurostat in hard copy, e.g. Key Data on Health 2002 and through New Cronos, Meeting and background documents of the Working Group on Public Health Statistics, of the Core groups and Technical meetings under the partnership for health statistics The report on the PHARE project on public health statistics (2001) Specific documents were: The Manual on a System of Health Accounts, made available by OECD in 2000, developed in cooperation with the partnership health statistics and Eurostat Implementing the Concept of Health Care Manpower in Member States on a Prototype Basis, BASYS 2004 The Guide to Producing National Health Accounts, provided by WHO, World Bank and USAID The SHA Guidelines: Practical guidance for implementing SHA in the EU, provided by ONS-UK focussing on the EU15; made under an agreement with Eurostat, Reports on Eucomp 1 and 2, from the North Eastern Health Board of Ireland, projects funded by the Commission, Working documents of Eurostat related to health care statistics, e.g. on SHA prototypes, manpower and hospital statistics 11

12 Final report 5 Project Implementation The work of the project was centred on three types of work Meetings Workshops Missions Besides, the project was run with coordination to grant contracts between Eurostat and the individual beneficiary countries. The project plan was as drawn up in the table below. Project plan PHARE 2003 Health Labour Accounts Content Date Kick off meeting and 1 st workshop Sofia April 2005 Missions June-October 2005 Deliverables from countries October nd workshop Riga October 2005 Final Meeting Riga 28 October 2005 Adjustment on deliverables 30 November 2005 Final report December 2005 The missions were carried out according to the table below. 12

13 Final Report Mission plan PHARE 2003 Health Labour Accounts D. Kawiorska Date M. Hjulsager Date Hungary 6-7/9 Hungary 6-7/9 Bulgaria 13-14/9 Estonia 12-13/9 Slovenia 15/9 Latvia 12-14/10 Slovak Republic 20-21/9 Lithuania 12-14/10 Czech Republic 22-23/9 Romania 12-14/10 The goals of the project were reached in a stepwise approach. All countries had due to the PHARE 2002 project on health accounts a relatively high knowledge on the methodological side of the question. However, the situation in terms of data sources was relatively different between countries. The project was consequently divided into three major parts and steps. 1. methodology To ensure a common starting point the basic methodology was repeated, and a framework model for development was created by experts. This work took mainly place during 1 st workshop and in missions. The framework model was combined with a suggestion for a stepwise approach for, including a priority in the work with. 2. Data sources and meta data The data source inventory from the PHARE 2002 project was used as a starting point. Experts created a framework for the meta data description of these data sources in relation to. These meta data descriptions were linked to the stepwise approach towards. 3. prototype data Experts gave advice to countries on initial collection of sample data as part of grant agreements between Eurostat and PHARE countries. For a number of countries complete or partly s was developed under the project. This was done building on the methodological knowledge in countries and the knowledge on data sources through the meta data descriptions. 13

14 Final report 5.1 Meetings There were three meetings with the participating countries and the experts. For efficiency reasons the final meeting was held back to back with the second workshop. The kick off meeting / 1 st workshop took place in Sofia on April 2005, hosted by the National Statistical Institute of Bulgaria. During the meeting the aims and objectives of the project were explained and discussed in the framework of public health statistics and according to the work programmes of Eurostat. The primary purpose of the kick off meeting was to introduce the project and its content, achieving to a common understanding. The primary purpose of the workshop was to introduce basic principals and the content of the work on health labour accounts (). The workshop did this by focusing on sources to, refreshing principals of, update on current state of affairs, discussions and practical work on basic principles and tables. The 2 nd workshop took place in Riga on October The workshop was held back to back with the final meeting. The primary purpose of the workshop was to present and discuss the results attained in the process of the project. Emphasis was on the meta data tables filled and delivered by countries, and prototype data for countries having these available. The final meeting took place in Riga on 28 October The meeting was held back to back with the 2 nd workshop. The primary purpose of the final meeting was to make a preliminary summary of achieved results attained in the process of the project. Final arrangements were made for submission of the final report. 5.2 Missions (per country) Missions were conducted in the mid phase of the project with in-depth bilateral discussions and from experts to countries advice on the subjects of the project. The main issues of missions were Evaluation of data source quality Cross classification of providers, national classification ICHA-HP Assistance to countries on grant contracts with Eurostat 14

15 Final Report To optimize missions the first one was conducted by both experts with responsibility for missions. This to coordinate and plan the following missions which was divided between experts and carried out individually. Prior to the missions a checklist for use during the missions was prepared and tested during the common experts mission to Hungary. The checklist was sent to countries before the mission for preparing more efficient discussions. The other purpose of the common mission was to test the documentary tables and to establish the framework model for the development of together with the stepwise approach. These documents were also sent to countries prior to missions. Below a short review of missions are repeated. For further details see mission reports for the individual countries. BULGARIA The mission to Bulgaria under the PHARE 2003 component of the Health Labour Account () was carried out on September The meetings took place in the Central Statistical Office with participation of persons from different departments of the Central Statistical Office. On the side of the beneficiary country the mission was very well prepared by Mrs Finka Denkova, the project leader, member of the Demography and Social Statistics Department of the NSI. On behalf of the ICON Institute the mission was executed by Dorota Kawiorska. The programme of the mission and its time framework were built during the mission and in general focused on the main points of the checklist. As a first point the aims of the project and the mission itself were presented by Dorota Kawiorska, the ICON expert. It was followed by discussion on different approach in the managerial and organizational aspects of the project and the role of the ICON experts in the process. The rest of the morning session was entirely focused on the framework model for the development of proposed by ICON experts and the clarification of the stepwise approach build for the purpose of this model. The afternoon session of the first day started with an overview of existing data sources inventory and its examination in order to define counting unit for manpower data compilation, to check out the plausible level of its attribution to HP classification as well as its delineation according to such dimensions like occupation, the level of education, and salaries. At the end of the first day the so called Bulstat code, an administrative individual code granted to each economic subject/unit, was discussed in order to use it for the purpose of creating a list of national actors in health care sector being defined by functional dimension of ICHA (HC.1-7). 15

16 Final report During the second day of the mission the selected points from the checklist were clarified in more detail way. This was followed by the discussion on the Terms of Reference of the contract agreement with the Eurostat focusing on such aspects of it like the time framework and the outline for the prototype data submission. As a last point the plausibility of the potential output for the workshop in Riga was considered given the advance of the actual work on. CZECH REPUBLIC The mission to the Czech Republic under the PHARE 2003 component of the Health Labour Account () was carried out from 22 to 23 September The meeting took place in the Institute of Health Information and Statistics (UZIS) with participation of persons from the Institute and the Central Statistical Office. On the side of the beneficiary country the mission was very well prepared by Jacob Hrkal and Sarka Kovackova, specialist from the UZIS. On behalf of the ICON Institute the mission was executed by Dorota Kawiorska. The programme of the mission was prepared by Jacob Hrkal and other members of the Czech team and agreed with the Icon expert prior to the mission (see the mission agenda in the second part of this report). At the start of the mission programme a general introduction of project, its aims and objectives as well as the mission itself were presented by Dorota Kawiorska, the ICON expert. It was followed by a description of the organisation of health care employment statistics in the Czech Republic by Jacob Hrkal and then by a presentation of the actual status of work carried out under the project. The second part of the morning session was entirely focused on the overview and the evaluation of existing sources for the. This part concerned the evaluation of metadata. The afternoon session of the first day started with a presentation of the framework model for the development of proposed by ICON experts and a clarification of the stepwise approach built for the purpose of this model. This was followed by an examination of the national list of health care provider and the problems which appear with its matching with ICHA HP categories. As a next step the determination of other dimensions like counting units, education and occupation was discussed with respect of the existing metadata on labour force in the health sector. On the side of the UZIS Mrs. Sarka Kovackova presented some metadata determinations with respect to an occupational and an educational classification. The second day of the mission mainly focused on a preliminary result of data compilation and discussing them. A presentation of preliminary findings was made by Jacob Hrkal. Depending on the methodological approach used for data compilation different findings were obtained. These differences appeared, among other, due to some borderline aspects of a provider and educational classifications. The potential 16

17 Final Report solutions and challenges linked with different approaches to data compilation were discussed in that respect. The afternoon session was devoted to the selected points form the checklist followed by a discussion on the Terms of Reference of the contract agreement with the Eurostat, its time framework and some organizational aspects of it. As the last point a potential output /presentation for the workshop in Riga was considered, given a highly advanced level of the actual work on. ESTONIA The mission to Estonia under the PHARE 2003 project component on Health Labour Account () was carried out October The meeting took place in the National Statistical Institute of Lithuania with participation of key stakeholders in the area of, see attachments. On the side of the beneficiary country the mission was very well prepared by Ms. Natalja Jedomskihh as responsible for in Latvia. On behalf of ICON Institute the mission was executed by Mr. Morten Hjulsager. Within the 2003 PHARE Project and its Health Labour Account component the work is organized with responsibility for the project and as well as SHA in general in the Ministry of Social Affairs. Other institutions involved in the project are The Health Care Board, National Statistical Institute, Ministry of Education and Research and Estonian Tax and Customs Board. The System of Health Accounts (SHA) is not used as framework for running production of health care statistics in Estonia. The first attempt for reconciliation of national classifications of expenditure toward ICHA was done in the PHARE project 2002 on Health Accounts. Estonia plan to use SHA as the central framework for but have no current decision on the starting time. With respect to only the provider dimension of ICHA is directly taken into consideration for metadata and data compilation. The aim is to reclassify the health establishments existing in national classification to HP categories of health providers. As a starting point the bottum-up approach is used. For the purpose of data a number of data sources are have been pointed out. HUNGARY The mission to the Hungary under the PHARE 2003 component of the Health Labour Account () was carried out from 6 to 7 September The meeting took place 17

18 Final report in the Hungarian Central Statistical Office, Population, Health and Welfare Statistics Department with participation of persons involved in the project from the Hungarian Statistical Office as well as outside experts from Semmelweis University, and National Health Insurance Fund Administration. On the side of the beneficiary country the mission was very well prepared by Ms Klara Feldmann and other colleagues from Hungarian Central Statistical Office. The programme of the mission was agreed with the Icon experts prior to the mission. On behalf of the ICON Institute the mission was executed by two experts Mr. Morten Hjulsager and Mrs. Dorota Kawiorska. Common mission of two ICON experts in Hungary had been pencilled for the purpose of exchanging experience and elaborating the mission s milestones via testing in practice the primarily prepared checklist for the missions, the documentary tables and to propose the framework model for the development of together with the stepwise approach. The aim of the proposed stepwise approach was not creation of the final roadmap to but a suggestion of one of several ways how to organize the works and to go ahead. As a first point a general introduction of project, its aims and objectives as well as the mission itself were presented by Morten Hjulsager, the ICON expert. The different organisational framework of the project in comparison to the SHA one was disused as a next point. It was followed by a presentation, done by Dorota Kawiorska, of the main points of checklist and the questions addressed to country teams in its framework. The second part of the morning session was entirely focused on the overview and the evaluation of existing sources for the presented by Mr. Imre Boncz (the head of Health Policy Department at National Health Insurance Fund Administration). The afternoon session of the first day started with a presentation of the actual status and achievements of work carried out under the. First of all the results of matching the Hungarian Health Care Classifications with the ICHA-HC dimension was presented by Mr. Vilmos Ivady (the general director of Health Services Management Training Centre at Semmelweis University). It was follow by discussion on pro and coin of using function versus provider dimension of ICHA classification. As a last point of the afternoon session Mr. Imre Boncz explained the possibilities and problems appear with classification of employment in Hungarian health care sectors by occupation and by level of education. The second day of the mission has started with discussion on problems with using available data sources mainly on such aspect as its biases and the risk of double counting of manpower. The last point of the morning session was focus on presentation of the framework model for development and the ICON expert s proposition of stepwise approach for metadata and data compilation. It was follow by clarification of the main steps of the model and details description of the all type of entries necessary for proper filing the documentary tables. During the afternoon session some issues of the country contract agreement was discussed. The aims, the program and expectations 18

19 Final Report with respect of the country presentation for the 2 nd workshop in Riga constituted the last points clarified during this mission. LATVIA The mission to Latvia under the PHARE 2003 project component on Health Labour Account () was carried out October The meeting took place in the National Statistical Institute of Lithuania with participation of key stakeholders in the area of, see attachments. On the side of the beneficiary country the mission was very well prepared by Ms. Dace Krievkalne as responsible for in Latvia. On behalf of ICON Institute the mission was executed by Mr. Morten Hjulsager. Within the 2003 PHARE Project and its Health Labour Account component the work is organized with responsibility for the project and as well as SHA in general in the Central Statistical Bureau of Latvia (CSB). For the project persons from several departments within the CSB are involved. The System of Health Accounts (SHA) is not used as framework for running production of health care statistics in Latvia. The first attempt for reconciliation of national classifications of expenditure toward ICHA was done in the PHARE project 2002 on Health Accounts. Latvia intend to use SHA as the central framework for but have no current decision on the starting time. With respect to only the provider dimension of ICHA is directly taken into consideration for metadata and data compilation. The aim is to reclassify the health establishments existing in national classification to HP categories of health providers. As a starting point the bottum-up approach is used. For the purpose of data a number of data sources are used. LITHUANIA The mission to Lithuania under the PHARE 2003 project component on Health Labour Account () was carried out October The meeting took place in the Depatment of Statistics to the Government of the Republic of Lithuania (Statistics Lithuania) with participation of key stakeholders in the area of, see attachments. On the side of the beneficiary country the mission was very well prepared by Ms. Sigita Maciuikiene as responsible for in Lithuania. On behalf of ICON Institute the mission was executed by Mr. Morten Hjulsager. 19

20 Final report Within the 2003 PHARE Project and its Health Labour Account component the work is organized with responsibility for the project and as well as SHA in general in the Statistics Lithuania, Social Protection and Health Statistics Division. For the project persons from several departments within the Statistics Lithuania are involved, as well as external partners. The involved institutions are besides the Statistics Lithuania, the Lithuanian Health Information Centre. The System of Health Accounts (SHA) is not used as framework for running production of health care statistics in Lithuania. The first attempt for reconciliation of national classifications of expenditure toward ICHA was done in the PHARE project 2002 on Health Accounts. Lithunia intend to use SHA as the central framework for but have no current decision on the starting time. With respect to only the provider dimension of ICHA is directly taken into consideration for metadata and data compilation. The aim is to reclassify the health establishments existing in national classification to HP categories of health providers. As a starting point the bottum-up approach is used. For the purpose of, data from a number of data sources are used ROMANIA The mission to Romania under the PHARE 2003 project component on Health Labour Account () was carried out September The meeting took place in the National Statistical Institute with participation of key stakeholders in the area of, see attachments. On the side of the beneficiary country the mission was very well prepared by Ms. Georgeta Marinela Istrate and Ms. Nicoleta Hrehorciuc-Caragea as responsible for in Romania. On behalf of ICON Institute the mission was executed by Mr. Morten Hjulsager. Within the 2003 PHARE Project and its Health Labour Account component the work is organized with responsibility for the project and as well as SHA in general in the National Statistical Institute, Department of Social Services. For the project persons from several departments within the Statistical Institute are involved, as well as certain external partners. The involved institutions are besides the National Statistical Institute, Ministry of Health, Center of Health Statistics and Medical Documentation, National House of Social Health Insurance. 20

21 Final Report The System of Health Accounts (SHA) is not used as framework for running production of health care statistics in Romania. The first attempt for reconciliation of national classifications of expenditure toward ICHA was done in the PHARE project 2002 on Health Accounts. Romania plan to use SHA as the central framework for. With respect to only the provider dimension of ICHA is directly taken into consideration for metadata and data compilation. The aim is to reclassify the health establishments existing in national classification to HP categories of health providers. As a starting point the top-down approach is used. For the purpose of, data from a number of data sources are currently examined. SLOVAK REPUBLIC The mission to Slovak Republic under the PHARE 2003 component of the Health Labour Account () was carried out on September The meeting took place in the Statistical Office of the Slovak Republic (SO SR) on the first day and in Institute of Health Information and Statistics (IHIS) on the second day of the mission. Both days experts from two the mentioned institution were participating in the meeting. On the side of the beneficiary country the mission was very well prepared by Alena Szücsová the project leader from the side of the SO SR and Mária Chmelová the expert from the IHIS. On behalf of the ICON Institute the mission was executed by Dorota Kawiorska. Preliminary programme of the mission was prepared by Alena Szücsová and other members of a Slovak team and was agreed with the Icon expert prior to the mission (see the mission agenda in the second part of this report). However during the mission some points of the meeting agenda were changed (the venue took place in two institutions instead of earlier plan to have it only in SO SR as well as for some areas more time was devoted than it was preliminary structured in meeting agenda). On the beginning a general introduction of project, its aims and objectives as well as the mission itself were presented by Dorota Kawiorska, the ICON expert. It was followed by presentation of the framework model for the development of proposed by ICON experts and the clarification of the stepwise approach build for the purpose of this model. The second part of the morning session and then the afternoon session was focused on an overview and evaluation of existing information sources for the purpose with respect to the possibilities of filling out the documentary tables and its detail description along the main questions of the checklist. At the end of the first day of the mission the discussion focus on the list of national actors and it was continued next day during the meeting at the Institute of Health Information and Statistics (IHIS). 21

22 Final report The meeting at the Institute of Health Information and Statistics was conducted by Mrs. Mária Konečná, the head of data Processing Department at IHIS. As the Institute both collects data on health employments in Slovak Republic and reports on its routinely the discussion focus on further examination of national list of health care provider and the problems appear with its matching with ICHA HP categories. Then the content of the existing IHIS data base was traced in details for the purpose of using additional information on other dimensions like counting units, education, occupation, and salaries of labour force in health sector. The last point of the mission focuses on the checklist and clarification of some questions of it. SLOVENIA The mission to Slovenia under the PHARE 2003 project component on Health Labour Account () was carried out on 15 September The meeting took place in the Institute of Public Health of the RS (IPHRS) and in the Central Statistical Office (CSO) with participation of local team experts from both institutions. On the side of the beneficiary country the mission was very well prepared by Mr. Tit Albreht, (the project leader) and others colleagues from the department for health care organization in IPHRS and by Stan Marn involved in the project from the CSO. On behalf of ICON Institute the mission was executed by Mrs. Dorota Kawiorska. One day mission to Slovenia was split for two sessions of which the morning one took place in Institute of Public Health of the RS (IPHRS) and the afternoon at the Central Statistical Office (CSO). During the morning session the aims of the project and the mission itself were presented by the ICON expert. It was followed by discussion on a background paper for the mission and additional materials that have been circulated to all participants prior to the missions. As a base for this discussion both the Slovenian sources inventory and information described under selected point of the checklist were evaluated and clarified. As a next point the use of stepwise approach and the possibilities of filling documentary tables were analyzed with respect to data sources administrated by Institute of Public Health of the RS. At the end of morning session the prototype data on 1 st digit level of ICHA-HP were presented by Slovenian team as well as some SHA borderline problems were discussed. The afternoon session was mainly focused on the possibilities of classifying employment in health care sector by salaries using as a main source the Tax Offices database. Due to agreement between the Central Statistical Office and the Tax Office it is probably possible to do it by information derived from this database. As a next step the issues of organizational and managerial aspects of project was disused with respect to sharing the information and knowledge that have been gained through the SHA project which was conducted by CSO. 22

23 Final Report 5.3 Trainings if any Training was not a specific objective of the project. However it is rather implicit from the objectives that some training is given while supporting the development of meta data and prototype. The development of new statistics on follows closely with training on the basic principles of the statistical system including SHA and its methodologies. The following subjects got special attention The SHA manual and its three core dimensions: financing agents, functional and provider classification with the special attention for the latter one The alternatives for creation a list of nation actors Boundary issues in health care Boundary issues of HRHC The issues of internal consistency of The importance of building consistency between and SHA The training took place mainly along four lines In meetings and workshops Discussions in working groups during meetings and workshops During missions Bilateral between national experts and project expert 5.4 Work phases The work phases of the project were basically linked to the deliveries by countries on the different outputs. The kick-off meeting and seminar introduced the project and the milestones of the project. Workshops were linked to the time frame of the deliveries. A workshop was held in the beginning of the project to present important methodology. A workshop was held in the end of the project to present and discus the work delivered by countries. The final meeting was held in the end stages of the project to close the project. Missions were held in between workshops and as such under the phase of work on output for countries. Missions were used for in-depth bilateral discussions. 23

24 Final report 5.5 Results achieved (per country) The results achieved by particular countries are described based on metadata information delivered by each country under two main documents prepared by ICON experts for the purpose of the project. That is on one hand the information described under the mission checklist and on the other hand the entries under the documentary tables. The entries for five out of eight documentary tables refer to metadata (tables 2 6) and the other to prototype data. Information on country prototype data accessibility/compilation is also presented within this section. results achieved per country refer to the metadata information, their final and / or earlier version, which was provided by each of the country to the ICON experts after (or before) the final meeting of the project, to be specific at the middle /end of November. Each of the countries had possibility to adjust and enrich their final output reports, according to expert s suggestions during the final meeting and/or bilateral country and expert cooperation after it. BULGARIA Criteria Comment on the outcome based upon the criterion listed Status at the beginning of the project Fulfilment of the project requirements Summary of the results achieved 3.1 approach Beginner. No direct experience. For the SHA purpose the data have been compiled using mixed the financing agents and provider approaches. For the purpose of the list of 24 national groups of actors has been created as a first step. The results presented by Bulgarian team fulfils the requirements of the project with respect to metadata compilation The deliverables recommended by ICON experts (i.e. the checklist filled with information concerned various aspects of creation the and 5 documentary tables filled with metadata) have been submitted on time. The prototype data has not been presented during the project final meeting nor sent out to ICON experts. The more detail description of the approach and methodology as well as prototype data are planned to be completed within the framework of the final report that will be submitted to EUROSTAT. -selected issues- Four information sources were identified of which two: the Survey of Health Establishments (SHE) and Enterprise Survey on the Number of 24

25 Final Report methodological aspects managerial aspects Employed Persons, Wages and Salaries and Other Labour Costs were chosen as the dominating and main complementary sources respectively. The bottom up approach was used. The results of the work show that in general available sources allow to cover 1 st digit level of ICHA-HP (except HP.5) and only partially 2nd digit level of it (it is foreseen to apply ICHA-HP on the 2 nd digit by using combination of Unified Identity Number of enterprises and NACE-Rev.1). The head count was chosen as primary counting unit. The manpower can be also classified by ISCO 88 (4 th digit level) and ISCED (only 1 st digit level) Wages of workers in health industry are considered to be included in in future. main problems: lack of one dominating source which can be use for purpose, linkage of different sources which have different aims, different coverage and different level of information details (information acquired via dominating source can be hardy transform to ICHA-HP classification), SHA borderline problems especially with health components of social care, problems with internal consistency. The works carried out under PHARE 2003 project () is organized entirely within the National Statistical Institute with involvement of persons from several departments (some problems with coordination of the works between different departments, the owners of the metadata and data). 4 Experts opinion with respect to plausibility of implementation Existing information sources / databases does not make possible for implementation at the moment. The extension of existing sources or implementation of the new ones should make the plausible in future. There is no plan for implementation at the moment. CZECH REPUBLIC Criteria Comment on the outcome based upon the criterion listed 1 Status at the beginning of the project Beginner. No direct experience. However, the list of national providers was used (converted) for the SHA project purpose and this fact has constituted both a good starting point for works carried under project and a solid base for ensuring the consistency between SHA and. 25

26 Final report Fulfilment of the project requirements Summary of the results achieved approach methodological aspects managerial aspects Experts opinion with respect to plausibility of implementation The results presented by Czech team fulfils the requirements of the project with respect to metadata compilation The deliverables recommended by ICON experts (i.e. the checklist filled with information concerned various aspects of creation the and 5 documentary tables filled with metadata) have been submitted on time. The prototype data has been presented during project final meeting. The more detail description of the approach and methodology is planned to be completed within the framework of the final report that will be submitted to EUROSTAT. -selected issues- Seven information sources were identified of which the Programme of Statistical Investigations of the Ministry of Health (Annual report on health personnel) was chosen as the dominating source. The bottom up approach was used. Supplementing the main source by information and data from other complementary sources lead to ensuring the completeness on the 3 rd digit level of HP classification with few exceptions (HP.3.4.1, HP.3.4.3, HP.4.3, and HP.6.3). The number of jobs was chosen as primary counting unit (head count and FTE are also considered to be used in future). The manpower can be also classified by national classification of health professions and ISCO. Wages of workers in health industry are considered to be included in. main problems: ensuring the internal consistency when using additional data sources on the top of the dominating one, identification and data collection on health care actors outside the Registry of health establishments, identifying the borderline between health and social care, using the FTE as a counting unit given the fact that different branches of health professionals use different concepts for its estimation, proceeding with the so called health care workers who are monitored according to their activities and not the level of their education. Two organizations are involved in project. The project is managed by the Czech National Statistical Institute and conducted (methodology, metadata and prototype data compilation) by Institute of Health Information and Statistics of the Czech Republic. The cooperation was perceived as a very good. Exiting information sources / databases make possible the implementation of. There is no national plan in that respect at the moment. 26

27 Final Report ESTONIA Criteria Comment on the outcome based upon the criterion listed Status at the beginning of the project Fulfilment of the project requirements Summary of the results achieved approach methodological aspects Beginner. No direct experience. However, Estonia has constructed health accounts using the SHA methodology, for the period and the PHARE 2002 initiative has provided an opportunity to verify the validity of the sources. For the purpose of PHARE 2003 project Estonia uses ICHA-HP as main classification for. All health care providers are classified by HP and this dimension was used as a starting point for data compilation for. The results presented by Romanian team fulfil the requirements of the project with respect to metadata compilation The deliverables recommended by ICON experts (i.e. the checklist filled with information concerned various aspects of creation the and 5 documentary tables filled with metadata) have been submitted on time. The prototype data has not been presented during the project final meeting nor sent out to the ICON experts. The more detail description of the approach and methodology as well as prototype data are planned to be completed within the framework of the final report that will be submitted to EUROSTAT. 27 -selected issues- Fourteen information sources were identified of which two i.e. Register of Health Care Professionals and Register of Chemists and Pharmacists were used as dominating ones. The others were used as complementary sources mainly for covering some gaps, completing other dimensions (like wages) and for checking out the consistency of the account. Mixed approach i.e. the bottom up and top-down were used depending on data sources. Metadata (and data) for HP.1, HP.3 and HP.5-HP.6 are collected by bottom-up method and data for HP.2, HP.4 are by top-down method. Supplementing the main sources by information and data from other complementary sources lead to ensuring the completeness at 2 nd and partially at 3 rd digit level of ICHA-HP. However there are some categories (HP and HP.4.), which are missing right now, but will be compiled from different sources until December The number of head count was chosen as primary counting unit (jobs and FTE are also considered to be used in future). The manpower can be also classified by ISCO 88 and ISCED 97. Wages of workers in health industry are considered to be included in in future. main problems: difficulty with elimination of double counting that might appeared due to necessity of compilation several different data sources, some borderline problems especially with respect to such HP

28 Final report managerial aspects Experts opinion with respect to plausibility of implementation categories like rehabilitations and nursing type of facilities), separation the suppliers of optical glasses and other vision products from other suppliers. Problems with existing individual data protection low has been mentioned as additional barrier for data compilation Two organizations are involved in project. The project was signed by Estonian National Statistical Institute but the work was carried out by Health Information and Analysis Department of the Ministry of Social Affairs. The cooperation was perceived as a very good. Exiting information sources / databases does not make possible for complete implementation of for the moment, however due to introducing some new complementary sources it is foreseen to be plausible in future. After completing the pilot works on the it is the plan to publish it officially by the Ministry of Social Affairs HUNGARY Criteria Comment on the outcome based upon the criterion listed Status at the beginning of the project Fulfilment of the project requirements Summary of the results achieved approach Beginner. No direct experience however many experiences with the SHA. (series of data are available for the years and the data of 2002 are under preparation now). The list of 17 national group of actors were identified for the purpose of project. However it was pointed out that the available information sources are more adequate for using ICHA-HC dimension than ICHA-HP for the purpose of The results presented by Hungarian team fulfils the requirements of the project with respect to metadata compilation The deliverables recommended by ICON experts (i.e. the checklist filled with information concerned various aspects of creation the and 5 documentary tables filled with metadata) have been submitted on time. The prototype data has not been presented during the project final meeting nor sent out to the ICON experts. It is planned to be delivered to Eurostat together with the final report -selected issues- Eight information sources were identified of which the Report on personnel of health care Statistical report on Health Personnel (National Statistical Data Collection Programme NSDCP 1019 and Data of the nonbudgetary health providers (National Statistical Data Collection Programme NSDCP 2016) were chosen as two dominating sources. The 28

29 Final Report methodological aspects managerial aspects Experts opinion with respect to plausibility of implementation use of other sources is planned to be tackled as a control information/data for the two main data sources. For the purpose the bottom up approach was followed. The results of the works show that in general available sources allow to cover 1 st digit level of ICHA-HP and only partially the 2 nd digit level of it (the NSDCP 1019 questionnaire need a manual review and classification in order to get the health employment data according to ICHA-HP 1-6. categories up to 2nd digits). For the moment missing categories on 2nd digits level of ICHA-HP are: HP2.2 HP.2.9; HP.3.1, HP.3.3, HP.4.1- HP.4.4; HP.6.1-HP.6.9). The head count was chosen as primary counting unit however data on jobs in term whether it is full-time or part time job is also available. The manpower can be classified by national classification of professions and the national classification of education (both classifications can be partially converted to ISCO 88 and ISCED 97 respectively. main problems concern involving the new data providers (the health care providers not reporting earlier) into the data collection system and making familiar the old data providers with the modified NSDCP questionnaire(s). The most important SHA boundaries problems arise in area where the interaction of health and social care exist The National Statistical Institute of Hungary has the main responsibility for the works carried out under this project For the purpose of project two outside experts from Semmelweis University, and National Health Insurance Fund Administration have been invited. The strengthening of the structure of the department responsible for development with respect to manpower and financial means was mentioned as one of critical point for the future works. Also some problems of coordination between institutions were pointed out given the timeframe of the project. Exiting information sources / databases does not make possible for complete implementation of for the moment. For successfully implementation of the necessity of extension one of main sources was pointed out. There is no official plan for implementation for the moment. 29

30 Final report LATVIA Criteria Comment on the outcome based upon the criterion listed Status at the beginning of the project Fulfilment of the project requirements Summary of the results achieved approach methodological aspects Beginner. For the SHA compilation primarily the financing agents approach was used however supported by provider side information. The final disaggregation of business registry was also done. For the purpose around 3400 national health care providers were identified and integrated into 42 groups of actors The results presented by the Latvian team fulfil the requirements of the project with respect to metadata compilation. The deliverables recommended by ICON experts (i.e. the checklist filled with information concerned various aspects of creation the and 5 documentary tables filled with metadata) have been submitted on time. The prototype data has been partially presented during project final meeting. It is planned to complete within the framework of the final report that will be submitted to EUROSTAT 30 -selected issues- Seven information sources out of twenty identified were used as a primary sources for metadata and data compilation. Three other sources were used only as supplementary data sources for cross checking data compilation, of which the Statistical Business register for creating the Local Register of Health providers. As a consequence of this work the bottom up approach was possible to follow up. The results of the works show that it is possible to classify the health providers by ICHA-HP, for the most part, in two digit levels. Furthermore an attempt was made to divide HP.3.4 and HP.3.9 in 3-digit level. For the moment missing categories concern among other HP (it is foreseen to obtain this information in future), and HP For such ICHA-HP categories like HP.2, HP.3.6, HP.4.4, and HP.6.4 further investigation is needed for elimination some departures from the content of these categories that appear for the moment. Furthermore for the purpose data evaluation was done by comparing three data sources The head count was chosen as primary counting unit however jobs and hours worked are also considered to be used in future. The manpower can be classified by ISCO and ISCED however the complete picture in that matter will be plausible in future. Similarly the salaries in health industry are considered to be included into in future. main problems: the precise/consistent linkage of different databases of health providers was solved partially thus it will need careful analysis in future. Some departures from the ICHA-HP categories have arisen mainly

31 Final Report managerial aspects Experts opinion with respect to plausibility of implementation due to boundary problems, mainly in the area where health care is overlapping with social care. These problems concern medicines for longterm nursing care facilities and homes for elderly, activities of the longterm nursing care facilities where at least one permanent medical staff is working, Spa and Sanatorium where rehabilitation services were not separated from non-health services or services of home care where the difficulties in dividing them by type of care (health and social services) still exist. Similarly like with SHA project the National Statistical Institute has the main responsibility for the works carried out under this project. Additionally for the purpose of two other institutions: Health Statistics and Medical Technology Agency plus State Agency of Medicines were invited. The cooperation was good. However the lack of political support, lack of time for discussion and deeper analysis of the results with main partners (MOH) was pointed out as a critical one of issues of this project. Exiting information sources / databases make possible the implementation of. To implement the on annual bases the National Statistical Institute has planned to finance this project as part of the 2007 budget. LITHUANIA Criteria Comment on the outcome based upon the criterion listed Status at the beginning of the project Fulfilment of the project requirements Summary of the results achieved Beginner. No direct experience. For the SHA purpose the data have been compiled using primarily the financing agents approach, however supported by provider side information. This facilitates the works carried out under the and has positive impact for ensuring the consistency between SHA and. The results presented by Lithuanian team fulfil the requirements of the project with respect to metadata compilation. The deliverables recommended by ICON experts (i.e. the checklist filled with information concerned various aspects of creation the and 5 documentary tables filled with metadata as well as 2 tables with prototype data) have been submitted on time. The prototype data has been prepared for the mission and presented during the project final meeting 31 -selected issues-

32 Final report approach methodological aspects managerial aspects Experts opinion with respect to plausibility of implementation Nine information sources were identified of which the Annual Report of Personnel in Health Care Establishment was chosen as the dominating source. The bottom up approach was used. The information gained from the main data source was completed by additional sources (due to the non-response) as well as in order to include data on providers which was not covered by the dominating one. As a result the 3 rd digit level of HP is covered (with few exceptions caused both by some HP categories not applicable within country system and information gaps (HP.6.4). The data available in the main source was compared with others data sources integrated in the Statistical Profile Business Register in order to avoid possible inconsistency (for the analysis data on income was used as an additional indicator). The head count was chosen as primary counting unit. The HRHC (within the main sources) was identified by professions and by the level of education using the national legislation and licensing rules and national classification of education respectively. Wages of workers in health industry are available however not within the main source. main problems concern the insufficient compliance between NACE and ICHA-HP classification. The use of the main economical activity of the establishment is impossible, even if at national level 6 digit level of NACE is used. This cause problems for example with selection of enterprises of retail sale of optical glasses as well as creates difficulties especially with such providers which according to the NACE are not under the health sector (retail sale and other provision of medical goods, social care, social insurance among other). Similarly like with SHA project, both the responsibilities and main works were carried out by the National Statistical Institute with some help of external partners Exiting information sources / databases make possible the implementation of. There is currently no plan for implementation of, and the implementation is determined by the international agreements on data provision and on the comprehensiveness of the data requested. In consequence there is no national plan for development at the moment. 32

33 Final Report ROMANIA Criteria Comment on the outcome based upon the criterion listed Status at the beginning of the project Fulfilment of the project requirements Summary of the results achieved approach methodological aspects Beginner. No direct experience. For the SHA compilation data have been compiled using primarily the financing agents approach. For the purpose a list of 50 groups of national providers were identified, however not all of them can be described against criteria due to lack of precise information sources. The results presented by the Romanian team fulfil the requirements of the project with respect to metadata compilation The deliverables recommended by ICON experts (i.e. the checklist filled with information concerned various aspects of creation the and 5 documentary tables filled with metadata) have been submitted on time. The prototype data has been partially presented during the project final meeting and documentary table no. 7 with prototype data was submitted to ICON experts. 33 -selected issues- Two out of nine information sources identified were used as primary sources for metadata and data compilation. The other sources were used as supplementary data sources for both the cross checking data compilation and covering the gaps. The top-down approach was possible to use at the moment; however it is planned to develop the bottom-up approach in future. The results of the works show that it is possible to classify the health providers by ICHA-HP, for the most part, on 1 st digit level and on 2 nd digit only partially. However even on the first digit (due to the top-down approach used) certain departures from the content of HP categories are visible. Those which was pointed out as substantive concern such categories like HP.2 (it includes some providers of social care services), and HP.5 (it include retail sale of some non-medical goods. The head count was chosen as primary counting unit however jobs, hours worked and FTE are also considered to be used in future. Depending on data sources the manpower can be classified by ISCO and ISCED, so for the moment these dimensions can not be used for purpose. Other dimension like age, gender, and salaries are available but only for 1 st digit level of ICHA-HP. main problems: the lack of more detail information sources which will led to development of bottom-up approach, linkage of different sources which have different aims, different coverage and different level of information details, problem with checking out the actual type of

34 Final report managerial aspects Experts opinion with respect to plausibility of implementation primary activity provided by registered establishment, problem with splitting total employment for HRHC and other employment, uncompleted list of actors (mainly due to various new types of establishments operating in private sector), problem with national classification of hospitals which does not fit for HP.1 category, other ICHA-HP departures as a consequence of top-down approach used. Similarly like with SHA project the National Statistical Institute, Department of Social Services has the main responsibility for the works carried out under this project. Additionally for the purpose of three other institutions: Ministry of Health, Center of Health Statistics and Medical Documentation, and National House of Social Health Insurance have been invited. The cooperation was good. Exiting information sources / databases does not make possible the implementation of at this moment. The existing data sources needs development in order to have the necessary information for compilation in future. There is no national plan for development at the moment, but the matter is under consideration. SLOVAK REPUBLIC Criteria Comment on the outcome based upon the criterion listed Status at the beginning of the project Fulfilment of the requirements Summary of the results achieved Beginner. No direct experience. For the SHA project data have been compiled mixing a financing agents and a providers approach. For the purpose the list of 28 groups of national providers was identified, however not for all of them has been possible to collect and describe metadata along the criteria due to lack of detail information. The results presented by the Slovak team fulfil the requirements of the project with respect to metadata compilation The deliverables recommended by ICON experts (i.e. the checklist filled up with information concerned various aspects of the and 5 documentary tables filled with metadata) have been submitted on time. The prototype data has not presented during the project final meeting. Country agreement under contract with Eurostat does not comply with data delivery. It focuses on metadata collection and details description of its methodology. -selected issues- 3.1 approach For the purpose of the metadata compilation three sources have been 34

35 Final Report methodological aspects managerial aspects Experts opinion with respect to plausibility of implementation pointed out of which the Annual Survey on number and structure of employees in health care M (MZ SR) 1-01) is treated as a dominating data source and the other as the complementary ones. The consistency among those data sources is planned to be check out by using information obtain from the Statistical Register of Organizations (NACE 5 digit level) and by using the IDENT code which is an identification code granted to each health type facilities. The bottom-up approach was used. The results of the works show that it is possible to identified the information on employment, within existing list of national health providers, for the most part, on 1 st digit level of ICHA-HP and only partially on the 2 nd digit of it. The head count was chosen as primary counting unit however the so called recalculated FTE is also available The manpower can be classified by ISCO and by national classification of education (convertible to ISCED) as well as by other dimension like age, and NUT but not for all categories on the 1 st digit level of ICHA-HP. main problems: the list of national actors is not completed and has to be a subject of changes/updates in nearest future due to the fact of current, ongoing changes within the health care reporting system. There is a problem with obtaining information on wages and salaries in the private health care facilities. Departures from the ICHA-HP categories appear mainly in the area where health care is overlapping with social care. The National Statistical Institute has main responsibility for project and cooperates with the Institute of Health Information and Statistics, which is specialized Ministry of Health agency for the area of health manpower statistics. The metadata compilation for the purpose of the project is mainly prepared by the Institute experts with support of Statistical Office experts who took part in SHA project. The cooperation is very good Exiting information sources / databases does not make possible the implementation of the for this moment. Data sources need to be extended and / or the new one develop in order to have the necessary information for compilation in future. 35

36 Final report SLOVENIA Criteria Comment on the outcome based upon the criterion listed Status at the beginning of the project Fulfilment of the project requirements Summary of the results achieved approach methodological aspects Beginner. No direct experience. For the SHA project data have been compiled using mainly the financing agents approach. For the purpose the list of 14 groups of national providers was identified. The results presented by the Slovenian team fulfil the requirements of the project with respect to metadata compilation The deliverables recommended by ICON experts (i.e. the checklist filled up with information concerned various aspects of the and 5 documentary tables filled with metadata) have been submitted on time. The prototype aggregate data has been presented during the project final meeting. Additionally table no. 1 with prototype data was also submitted to ICON experts 36 -selected issues- For the purpose of the metadata compilation ten sources have been pointed out of which the National Health Care Providers Database (NHCPD) is treated as a dominating data source and the other as complementary ones. The consistency of is perceived as very good due to the fact that the main source covers all health institution and includes information on all type of health care professional, on all type of their employment, and on health professionals who currently or permanently working outside of health care sector. The linkage with ICHA-HP is possible however some departures from the HP categories exist. The manpower can be classified by national classification of education and occupation (the latter corresponds to ISCO). As counting unit head count, FTE, total hours works and jobs is available. Additional dimensions under which manpower can be traced are age, gender, and geographical region among other. The bottom-up approach was used. The results of the works show that it is possible to identify the information on employment, taking into consideration the existing list of national health providers, on 1st digit level of ICHA-HP and partially on the 2 nd digit of it. Missing HP categories are: HP , HP (except HP.3.4.5), HP , and HP The head count was chosen as primary counting unit and for data presentation. Beside HRHC and other employment an additional group of other health personnel was identified (it concern the health personnel which due to lower then 3 rd level of education cannot be included in HRHC according to rules. main problems: creating more detail list the list of national actors and its describing against criteria, eliminating some departures from

37 Final Report managerial aspects Experts opinion with respect to plausibility of implementation the content of ICHA-HP categories (HP ), linking the employment with salaries. Future development will require: the introducing internationally recognized classifications and their implementation in the health care sector, developing a stable methodological team to maintain and develop further the activities related to, and co-ordination with the SHA project to ensure its coherence and consistency. Institute of Public Health has main responsibility for the project. Additionally the National Statistical Institute which was responsible for the SHA project was invited for cooperation Exiting information sources / databases make possible the implementation of the for this moment. There is currently no valid and adopted national plan for development of. 5.6 Results: All countries For the purpose of PHARE 2003 project and its component two main types of documents have been prepared by experts. 1. The checklist in order to structure and coordinate the missions. This checklist was constructed in the way that could be used beyond missions, to structure the output of the project. It covers a number of questions to be answered /described depending on the level of advance of works that have been carried out under the project. 2. The metadata working tables (available in excel spreadsheets) in order to facilitate the process of metadata collection and its documentation. Additionally the stepwise approach to initial phases of has been developed with aim of clarification and smoothing the process of filing up the metadata working table. Further more from the PHARE 2002 project a data source inventory was made. During the project a framework model and a suggestion for a stepwise approach to the development of was created. The framework model take a starting point in the basic requirements for as described in the SHA manual. These are Borderlines according to SHA (ICHA-HC 1-7) Counting unit Branch Occupation Education 37

38 Final report The framework model for is mend as basis for the development of, and the model is not a manual for or guidelines to. Consequently the model is meant to serve as background and inspiration. Besides a set of priorities in respect to the content of, pointing at the important core elements of ( ideal ). The model can also be used as a starting point for methodological work on In the Annex the model is depicted in a figure. On the basis of the framework model for the development of, it is logical to proceed in a stepwise approach. The stepwise approach is not a final roadmap to, but covers the initial steps and is one of several ways to go ahead. Specific country conditions determine the right way for each country, e.g. available data sources, organisation plus financial and human resources available. The stepwise includes the following steps 1. Create list of national health care actors (providers) 2. Map the national actors with ICHA-HP 3. List of information sources 4. Map the national actors with information sources 5. Link actors and sources with selected dimensions 6. Additional information In the Annex the steps are described in further detail. Data source inventory The data source inventory in respect to was carried under the PHARE 2002 project. Within the PHARE 2003 project on the output was used as a starting point. Countries were asked to update the data source inventory, but no countries found a need for this. Most likely due to the close time link between the two project. The data source inventory in respect to was carried out using a standard table structure. The structure was designed to give overview on central points related to employment statistics in the framework of health accounts (SHA). Certain elements are crucial in respect to development of health labour accounts. The data source inventory is done taken into account the total manpower in the health care sector, including e.g. both public and private sector, both authorised and non-authorised personnel. The data source inventory should specifically address the following points for each data source 38

39 Final Report 1. Name of data source 2. Method of collection (e.g. sample, register) 3. Data collection by one point in time (status), or over a time period (average) 4. How is manpower counted (e.g. head count, full time equivalence, total hours worked, jobs) 5. Classification of the level of education 6. Classification of occupation (function) 7. Classification by ICHA-HP is possible 8. Differences to the SHA manual in respect to borderlines and/or functions 9. Differences to the SHA manual in respect to other items 10. Quality of data source 11. Other dimensions (E.g. gender, age, geography) For relevant points the description included the classification used. With being a multi source exercise it is important to have clear information on similarities and differences between the data sources. From the data source inventory it is noted, that The number of data sources vary across countries, from 3 to 11 as the outer points All countries have in one or more data source differences to the SHA manual All countries have in one or more data source the capacity to map into the ICHA-HP classification Head counts and full time equivalents are the most predominant counting measures All countries have implemented national or international classifications on education and occupation in one or more data source In the table below the results for all countries are summarized. Data source inventory (carried out under the PHARE 2002 Health Care statistics) Number of reported data sources 1 Counting Unit ICHA-HP Education Occupation Differences to possible 2 SHA manual Bulgaria 4 HC/Job Yes Yes Yes Small providers (<10) Czech Rep. 6 HC/FTE Yes Yes Yes Borderlines Estonia 7 HC/FTE/Hours Yes Yes Yes Non-medical personnel Hungary 6 HC/FTE Yes Yes Yes Borderlines, definition of 39

40 Final report providers Latvia 11 (17) HC/Hours Yes Yes Yes Borderlines, local units (multiproduction) Lithuania 9 HC/FTE/Hours/Job Yes Yes Yes Borderlines, division of totals Poland 8 (27) HC/FTE/Hours Yes Yes Yes Borderlines Romania 7 HC/FTE Yes Yes Yes Borderlines Slovak Rep. 3 HC/FTE Yes Yes Yes Borderlines, definition of providers Slovenia 6 HC/FTE/Hours/Job Yes Yes Yes Borderlines, definition of providers Note: If for just one of the reported data source a given characteristic is present, it is marked. 1 For countries with a number in parentheses, this reflects a split of registers regarding authorized health personnel in the reporting. 2 Yes implies not necessarily that all HP-categories can be done, but that one or more of the reported data sources has the capacity for mapping to ICHA-HP. Checklist First of all it can be said that all countries can be considered as beginners in other words they have no statistics available related to SHA. They all started from point zero. Summarizing the information provided by countries within the checklist it can be stated that eight out of nine countries have used the bottom-up approach when compiled the prototype metadata and data. Taking into consideration to the issue of general completeness of the with respect to ICHA-HP dimension, five countries show the possibility of classifying the employment on the 1 st digit level and only partially on the 2 nd digit level. However within this group of countries both a single gaps and departures from the content of HP categories appear even on the 1 st digit level of ICHA-HP classification. Next two countries show the possibility to classify the employment on the 2 nd digit level of ICHA-HP dimension and partially on 3 rd digit level. Only two countries demonstrated the potential for matching employment with 3 rd digit level of ICHA-HP classification. 40

41 Final Report As regards the internal consistency of data sources only five countries represent relatively good level of it comparing to all others countries where additional investigation is both necessary and highly recommended. The existing differences among countries can be explained by several factors, among other by: Starting point for SHA data compilation and its completeness. In these countries where the staring point was provider approach or where data compiled from the financing agents approach has been checked out by provider side it was easier to construct the list of national actors which met the SHA borderline criteria. The existence of one dominating data sources/database which provides information enough details for both matching national actors with categories of ICHA-HP classification and breaking down the employment against selected criteria The level of adjustment of national classifications with respect to occupation and education to ISCO 88 and ISCED 77 The level of advance of national commitment toward the SHA implementation as well as the cooperation among institutions that have been involved in project It should be also pointed out that in all countries national system of health manpower statistics exist in the more traditional sense. as a new system is not widely known or used, and except one country there is no budget pencilled for the activity. Two countries have concrete plans for development at the moment and one country considers developing a plan (see table below). 41

42 Final report Summary results with respect to selected points of the checklist (countries outputs corrected and submitted to ICON experts on ) Approach used Evaluation of completeness with respect to ICHA-HP Evaluation of internal consistency of The need for extension existing or development of new data sources National plan for development Bulgaria Bottom-up 1 st digit level (2 nd only partially ) Czech Rep. Bottom-up 3 rd digit level Estonia Bottom-up and top-down of ICHA-HP 2 nd digit level (3 rd partially) Hungary Bottom-up 1 st digit level (2 nd only partially) Latvia Bottom-up 2 nd digit level (3 rd only partially) Need further investigation Relatively good Need further investigation Relatively good Relatively good Lithuania Bottom-up 3 rd digit level Relatively Good Romania Top-down 1 st digit level Need further investigation Slovak Rep. Bottom-up 1 st digit level (2 nd only partially Slovenia Bottom-up 1 st digit level (2 nd only partially Need further investigation Relatively good Yes Yes Yes Yes Yes Yes Not considered at the moment Not considered at the moment Plan for annually compilation in future Not considered at the moment Plan for annually (2007) Depends on international agreement on the matter Under consideration Not considered at the moment Not considered at the moment Meta data working tables Five out of eight metadata working tables were created for metadata entries (tables 2-6) and three others (table 1, 7 and 8) for data entries. The sequence of the tables (except 42

43 Final Report the table no.1) reflects the stepwise approach recommended by ICON experts to be followed when the process of metadata collection starts. Within this process five steps were recommended: Create list of national health care actors (providers) Map the national actors with ICHA-HP List of information sources Map the national actors with information sources Link actors and sources with selected dimensions All countries have filled in tables prepared for metadata documentation (see table below). Table 2 of the meta data working tables shows the number of national providers (the list of national actors) that have been taken into consideration for metadata and data compilation. The number of national providers waves between 14 and 117 units/establishments which reflect, among other, the level of completeness with respect to ICHA-HP dimension. Behind this grouping of provider s lies for some countries several thousand establishments found through business registers. Summary of results with respect to the content of metadata working tables (countries outputs corrected and submitted to ICON experts on ) Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Bulgaria - +(24) + +(4) Czech Rep. - +(117) + +(6) Estonia - +(35) + +(14) Hungary - +(17) + +(8) Latvia - +(42) + +(20) Lithuania + +(50) + +(9) Romania - +(46) +/- +(9) + +/- + - Slovak Rep. - +(28) + +(3) + +/- - - Slovenia + +(14) + +(10)

44 Final report Summarising other information provided by countries within the metadata working tables it is noticeable that for the majority of the countries the prevailing manpower counting unit is head count. Jobs is considered as primary counting unit only in one country (the Czech Republic) and there is also only one country i.e. Slovenia where existing database give the possibility of using different type of manpower counting units. The possibility of classifying manpower by occupation and by the level of education is demonstrated by all countries either by the respective national types of such classification or by international standard classification i.e. ISCO 88 and ISCED 97. In several countries where national types of classifications were pointed out its conversion for international standard classification is usually possible. However it does not means that splitting among HRHC and other employment is plausible for all countries. From the materials delivered by countries to the ICON experts such possibilities exist and was examined with prototype data in case of three countries i.e. Czech Republic, Lithuania, and Slovenia. Two of them (Czech Republic and Slovenia) have faced the problem with including or excluding from HRHC the group of lower (below third level) educated health personnel which according to national policy belongs to HRHC and is reported as such within the national health employment statistics. As a temporary solution this group was reported separately and not included either under HRHC or under other employment categories. Similarly with others dimension (age, gender, NUTS and salaries) the countries declaration for possibility of additional classification of employment cannot be verified for the moment (except Slovenia where exist very comprehensive database) due to the fact that such possibility usually exist within one or two particular sources of information and is not available for all sources that were used for metadata compilation. Therefore, again only data compilation may at the end show the feasibility of classifying employment according to particular (additional) of dimension. The table below shows the total number of sources that have been examined for the purpose of the project. Summary of results with respect to selected criteria of the metadata working tables (countries outputs corrected and submitted to ICON experts on ) How manpower is counted Classification of occupation Classification of education Other dimension Bulgaria Head count ISCO ISCED/National NUTS, (expenditure) Czech Rep. Jobs National /ISCO National /ISCED gender, age, NUTS expenditure (depending on 44

45 Final Report Estonia Head count ISCO ISCED or nationals depending on sources sources) Hungary Head count, National/ ISCO National/ISCED NUTS Latvia Head count, ISCO (depending on sources, to be completed in 2006) Lithuania Head count National /Licensing rules Romania Head count, jobs, FTE ISCO /national (depending on data source) ISCED (depending on sources, to be completed in 2006) (HRHC national classification available within the main source) ISCED/national (depending on sources) Slovak Rep. Head count ISCO ISCED/national Slovenia Head count, FTE, jobs, hours worked (depending on sources) gender, age, NUTS expenditure (depending on sources) Gender, age, NUTS, expenditure Gender, NUTS, expenditure Gender, NUTS, Expenditure Gender, Age, NUTS ISCO 88 National Gender, age, NUTS Summary of results All beneficiary countries, except Poland, participated in the project. The countries made great efforts (1) to become familiar with the methodology, (2) to investigate potential national sources and (3) to develop prototype data under the separate contractual arrangements with Eurostat. The project could benefit from the previous ICON-Eurostat project on the System of Health Accounts (SHA). Experts and staff from countries were almost the same persons. And because the builds on the methodology of SHA, the step from SHA to was rather easy. The common issues, e.g. on the boundaries, could be treated equally in both subjects and in this way synergy was guaranteed and optimal comparability will resulting from future simultaneous analysis of SHA and. All countries have followed the proposed stepwise approach, filled the prepared materials, and thus fulfil the requirements of the project (ICON) with respect to metadata description. However it has to be brought up that the level of information details presented within the framework of above mentioned materials varies among the 45

46 Final report countries as well as the majority of countries have declared its improvements and completion before sending the final version to Eurostat. This improvement/completion concerns not only the metadata description but also the submission of prototype data that was a subject of particular country contract agreement with Eurostat (except Slovak Republic). Four out of nine countries have presented the prototype data during the final meeting of the project (28 October, 2005 in Riga). For two of them i.e. for the Czech Republic and for the Lithuania the process of prototype data compilation seems to be completed and for two others i.e. for the Romania and for the Slovenia some amendments / adjustments might be done / expected before sending the final compilation to Eurostat. Summary of results with respect to metadata documentation (PHARE project) and prototype data availability (countries outputs corrected and submitted to ICON experts on ) Checklist Meta data working tables Prototype data Bulgaria Filled in 5 out of 8 tables Not available Czech Rep. Filled in 5 out of 8 tables Available Estonia Filled in 5 out of 8 tables Not available Hungary Filled in 5 out of 8 tables Not available Latvia Filled in 5 out of 8 tables Not available Lithuania Filled in 7 out of 8 tables Available Romania Filled in 6 out of 8 tables Available (only for total employment) Slovak Rep. Filled in 5 out of 8 tables Not applicable Slovenia Filled in 6 out of 8 tables Available However there remain some specific providers with particular borderline problems: nursing and residential care facilities, retail sale and other providers of medical goods, insurance. The additional elements, e.g. number and type of staff and full time equivalents required extra attention. Also because of the differences in staff and working hours between countries these subjects require further investigations aiming at EU wide accepted common concepts and whenever necessary evidence based convergence keys. The available detailed national sources proved to be excellent building blocs for getting overviews and for further developments of data on. However in some countries the growing number of private run health services, e.g. private practitioners and dentists cause some concern and an extra burden to obtain reliable information. Special 46

47 Final Report attention is also required for potential double counting, e.g. staff employed in public service health institutes and running partially a private practice. The project supported the prototype data project which is subject of a direct contract between countries and Eurostat. Participants expressed there satisfaction in this respect. However the experts can not evaluate this point because the prototype data are delivered directly to Eurostat. 47

48 Final report 6 Recommendations for future steps to be undertaken in the Project Area Based on the project a number of recommendations can be drawn up. These are divided below between beneficiary countries and Eurostat. 6.1 by Beneficiary Country Through the bilateral consultancies with countries a number of country specific recommendations are drawn up. BULGARIA Check out the list of national actors against the SHA borderlines Detail evaluation and description of national concepts, definitions, and estimation methods used for health employment statistics Description of a departure from the contents of the ICHA-HP categories Further investigation on consistency between the information sources used for purpose Check out the results of metadata investigation with the prototype data results If possible propose the way of existing data sources extension or development of the new ones which will help with completing compilation in future CZECH REPUBLIC Detailed evaluation and description of concepts, definitions, and estimation methods used in the national statistics of health employment Reporting on departures from the contents of the ICHA-HP categories Detailed description of methodological approach used for the data compilation especially in areas where SHA concepts/borderlines are not precisely identified at the moment. ESTONIA Check out the list of national actors against the SHA borderlines Detail evaluation and description of national concepts, definitions, and estimation methods used for health employment statistics Description of departure from the contents of the ICHA-HP categories Examine consistency between the information sources used for purpose especially for elimianting double counting with self-employed physicians who works in several institutions. Check out the results of metadata investigation with the prototype data results HUNGARY Evaluation of the list of national actors against the SHA borderlines Detailed evaluation and description of concepts, definitions, and estimation methods used in the national statistics of health employment Examine consistency between the information sources used for purpose Reporting on departures from the contents of the ICHA-HP categories 48

49 Final Report Detailed description of methodological approach used for the data compilation especially in areas where SHA concepts/borderlines are not precisely identified at the moment. Check out the results of metadata investigation with the prototype data results If possible propose the way of existing data sources extension or development of the new ones which will help with completing compilation in future LATVIA Check out the list of national actors against the SHA borderlines Detail evaluation and description of national concepts, definitions, and estimation methods used for health employment statistics Description of departure from the contents of the ICHA-HP categories Examine consistency between the information sources used for purpose Check out the results of metadata investigation with the prototype data results LITHUANIA Check out the list of national actors against the SHA borderlines Description of departure from the contents of the ICHA-HP categories Examine consistency between the information sources used for purpose Consider possible development of the employment counting unit from head counts to jobs / FTE / hours worked Consider possible development of data sources with international classification of occupation and education ROMANIA Complit the list of national actors and check it out against the SHA borderlines Detail evaluation and description of national concepts, definitions, and estimation methods used for health employment statistics Description of departure from the contents of the ICHA-HP categories Sorting information on local actors and other information relating them to the ICHA-HP classification Examine consistency between the information sources used for purpose If possible propose the way of existing data sources extension or development of the new ones which will help with completing bottom-up approach compilation in future SLOVAK REPUBLIC Evaluation of the list of national actors against the SHA borderlines and the potential departures from the content of HP categories. When examining the list of national actors to use the IDENT code for checking the internal consistency of metadata Reporting on departures from the contents of the ICHA-HP categories To build a cross-matrix between national classification of education and ISCED Detailed evaluation and description of concepts, definitions, and estimation methods used in the national statistics of health employment Check out the results of metadata investigation with the prototype data results If possible propose the way of existing data sources extension or development of the new ones which will help with completing compilation in future 49

50 Final report SLOVENIA Extend the list of national actors and check it out against the SHA borderlines Detail evaluation and description of national concepts, definitions, and estimation methods used for health employment statistics Description of departure from the contents of the ICHA-HP categories Detailed description of methodological approach used for the data compilation especially in areas where SHA concepts/borderlines are not precisely identified at the moment. Examine the possibility of possessing information on salaries in health care sector 6.2 by Eurostat A key source for labour marked issues is the Labour Force Survey. However, for the domain of health there is no specific breakdown and the data are together with other social care services. Therefore the will be a valuable and useful complementary source for the specific domain of health services. For health services and its detailed producer oriented health policy it may also become a better source for comparisons between member states because of the harmonisation of these statistics based on the SHA principles and its links to national accounts. In this respect it will also become a strong tool for obtaining better inside in the effect of health manpower developments in national and European financial frameworks. It is recommended to Eurostat that further methodological issues are explored in respect to. This goes in regards to counting unit and the other dimensions of (education and occupation). This should lead to a concept as a common standard for EU and suggestions for convergence keys from national concepts and practices on towards the EU standard. Including this, further attention should be given to the categories of providers with borderline problems. For a number of provider s health care is not the primary economic activity, leading to a need for imputing the share of total employment in these providers involved in delivering health care services within the SHA borderlines. An other issue, which should be developed gradually, is the combined analysis of SHA and. Since in EU a large share of health care expenditure is on personnel, is a crucial explanatory variable for developments in SHA. Prototype analysis of combining SHA and may enhance the use of both statistics for a better understanding of developments on health care expenditure and financing, both in terms of national differences and trend developments. Eurostat should consider developing actual guidelines for as is the case for SHA. And the guidelines should be consistent with SHA. The methodological development and guidelines on this basis of this, is necessary for a development of harmonised 50

51 Final Report statistics in EU. The results within this project in terms of the framework model and stepwise approach towards can be seen as early steps to a developed methodology. Next Eurostat should consider regular training on statistics preferably in relation to training on SHA. However in the EU there is a shortage of experienced statisticians in these domains. Therefore a programme for training of trainers should be given serious consideration. 51

52 Final report 7 Conclusions The project on health labour accounts is part of a larger PHARE project which includes also other statistical domains covered by Eurostats regular programmes. The project aims at assisting beneficiary countries with the adaptations of the national statistics required for regular reporting to Eurostat according to the agreed standards and technical specifications. The aim of the project was the development of necessary elements for a later implementation and sustainability of in beneficiary countries. The project was coordinated with grant contracts between Eurostat and the individual countries on the same subject. For almost all countries these contracts includes the development of prototype data, with the PHARE project supporting this. In the present project the emphasis were on three main parts The evaluation of data sources available for Preparation for compilation of data in comprehensive multi-source data systems such as Assist countries on an initial collection of sample data by Eurostat (under grant agreement between Eurostat and the individual countries) For building up the end goals stepwise, the work was structured in phases. The project was divided into three major parts and steps. 1. methodology 2. Data sources and meta data 3. prototype data It can be concluded, that all participating countries fulfilled the content of the PHARE project. For all countries a number of relevant data sources was pointed out, and the quality of these data sources were examined. Experts gave countries advice on adjustments of existing data sources or need on development of new data sources. All countries described the status and work on with the mission checklist and data sources in the meta data working tables developed within the project. In respect to meta data working tables a variation of tables were filled out across countries. 52

53 Final Report For a number of countries complete or partly s was developed during the timeframe of the project. The development was done according to grant contracts between countries and Eurostat, and as such determined by these contracts. The further development beyond the timeframe of the PHARE project and reporting on the contracts are done to Eurostat directly. Based on the project, it can be concluded that methodological work on is needed. Also a set of guidelines on how to develop is needed in order to have harmonised statistics within EU. Further more, there is a need to create the necessary human resource basis in Europe for, and for this regular training at the European level is needed. 53