Technical brief on the Indicators published on the World Health Organization s Global Health Expenditure Database

Transcription

1 Technical brief on the Indicators published on the World Health Organization s Global Health Expenditure Database Introduction WHO s Global Health Expenditure Database (GHED) is a global public good that provides harmonised health expenditure estimates and indicators for over 190 countries from the year 2000 onwards. This technical brief is intended to provide readers with the background information they require to understand the database content as well as how the indicators are calculated. This year, the data are reported using the framework of System of Health Accounts 2011 (SHA2011). The new classifications now capture more accurately health financing reforms taking place in Member States, and enables more insightful and policy relevant analysis to be conducted than was previously possible. In this year s data release the emphasis is on the resources (or financing sources) and the financing schemes (the arrangements through which the spending is being made). GHED includes for over 190 countries between estimates of current health expenditure (CHE) and capital investments (HK). The separation of current and capital expenditures improves comparability across and within individual countries and over time, as capital expenditures fluctuate and do not finance access to health services, but improve future resilience of the health sector. CHE refers to all health care goods and services used or consumed during a year whereas capital spending (or rather gross capital formation ) includes purchases of new assets which are used repeatedly over several years. HK includes investments into buildings, machinery, IT together and stocks of vaccines for emergency or outbreaks. Each country s health expenditure estimates are available in absolute amounts in national current units (NCU) and common currencies including US dollars (USD) and international dollars at purchasing power parity (PPP). Together with the publication of new estimates of health expenditures a new set of indicators were developed which clearly show what share of funding comes from domestic and external sources, how much the public sector spends on health as well as the extent to which governments subsidize health insurance systems. Indicators help policy makers and other stakeholders monitor progress towards Universal Health Coverage (UHC), evaluate the impact of health reforms, and compare countries and trends over time. There are two main types of indicators used for international comparisons: percentage shares and per capita values. These indicators are organised into 4 broad groups: i. summary indicators, ii. indicators of sources of health spending, iii. indicators describing financing arrangements, and iv. cross-indicators, describing transfers from government to social health insurance. 1

2 To calculate many indicators, macro-economic and demographic estimates from other organizations, such as the World Bank, IMF and United Nations Population Division were used. Data sources for each data point are described in a metadata section. This technical note is organized into 3 parts, first describing what is new in GHED, in the second part you can find a description of the health expenditure data and in the last part an explanation of how the indicators are calculated. Detailed formulas for the calculation of the indicators are available in the annex. 1. New information in the Global Health Expenditure Database There a several changes in this year s database. The separation between current and capital expenditures is one of them. Estimates of current health expenditures include consumed healthcare goods and services during each year and capital expenditure capture how much was invested into the health infrastructure. Infrastructure expenditure tends to be volatile and can in some countries misrepresent the information on how much resources was available to fund consumption of healthcare. Investments into health infrastructure support the resilient health systems and the new estimates will help us better understand how countries invest into the future of their health systems. Until this year, the GHED reported spending by financing agent, the intermediary that executed the payment, such as a Ministry of Health, Statutory Health Insurance Fund, or a Non-Governmental Organization (NGO). While useful, this organization of the data hid the actual sources of these expenditures. The source of expenditure was added this year (referred to as the FS classifications). All health expenditures from external sources can be now distinguished from domestic sources which can be further divided between domestic public and private sources. Public sources stem from taxes or mandatory insurance contributions, private sources include voluntary prepayment or direct out of pocket payments. Subsidizes to insurance systems from general budget will become visible under the new health expenditure estimates as well as further details of health expenditures. Health expenditure by the financing agents was guided mainly by its institutional feature (such as ownership), historical models of health financing and sometimes even their names. The financing arrangements (referred to as the HF classifications) allows determining the shares of health expenditure that flow through prepaid and pooled mechanisms with compulsory or automatic coverage, distinct from voluntary prepaid arrangements and out-of-pocket spending (OOPS). The new classifications enable a more explicit assessment of how countries rely on compulsory/automatic coverage in their financing arrangements. The three main distinguishing criteria are whether participation (coverage) by the arrangement is automatic, mandatory or voluntary; whether entitlement to benefits/services is based on contribution or some other factor (citizenship, residence, poverty status) and whether there is interpersonal pooling of the funds. The main types of arrangements are government organized schemes including social health insurance, voluntary health insurance or household out of pocket payments. It is very important for policy makers to have accurate information of the level and mix of funding, the channels for health expenditures, and their trends over time. Each financing arrangement is funded from 2

3 different sources and thus a self-standing classification of sources of health spending has been introduced under the framework of SHA2011 and implemented in GHED. The FS classifications offers information on the size of external or domestic sources of health expenditures, as well as the relative size of domestic public and private expenditures. Taxes or mandatory contributions to health insurance are the main public sources whereas out of pocket payment and voluntary contributions are the main sources of private expenditures. The size of health expenditure from external sources flowing into each country will be captured both when they flow though the government budget and through local NGOs. These methodological changes provided an opportunity for all countries to review their estimates of health expenditures between and any changes are reported for each observation in the country metadata files. This is also true for the macro-economic variables which were updated, and which are used to calculate some indicators. What are the differences between the SHA1.0 and SHA2011 classifications Health expenditure estimates are used by politicians, policy-makers, citizens, media as well as researchers to understand the health system or monitor impacts of health reforms over time and to compare countries. The Global Health Expenditure Database in its new version is the reference source for health expenditure for international comparison imbedded in a standardized framework. The SHA2011 clarifies the financing mechanisms and introduces new dimensions which improve the comparability of health expenditures in the perspective of the UHC. The main differences between the previously published data and the new data in GHED are: Separating current from capital expenditures and reporting Health Expenditures (CHE) and Capital Health Expenditures Identifying the main source of health expenditure, such as taxes or social health contributions (public), from voluntary prepayment, out-of-pocket payments (private) and from external donors (external) Enabling comparison between countries and how they arrange the main financing arrangements, providing more nuance on the entitlement, pooling and benefit design, Introducing current expenditures on health The health expenditure estimates separate current expenditure and gross capital formation. Current health expenditure refer to all health care goods and services used during a year tend to be relatively stables whereas gross capital formation can spike in some years impacting on the comparison of health expenditures among countries. In the database, the gross capital formation will be reported separately under the capital account. Purchases of new assets which are used repeatedly over more years, or to be used in future will be reported. This includes investments into buildings, machinery, IT together with the increased stock of vaccines for emergency or outbreaks. We observe large fluctuations in size of capital expenditures (between 0-20% of total health expenditures) which will affect the indicators in some countries. Focusing on capital expenditures will improve the health expenditure estimate as some 3

4 countries might have omitted reporting their capital expenditure leading to under-reporting of their total health expenditures. Separation of capital spending will not influence the total health expenditure as they are composed of current and capital expenditures. In general we can expect that the current health expenditures are lower than total health expenditures, and such decrease will be more pronounced in lower income countries which are investing heavily into their health infrastructure. Source of health expenditure The source of health expenditure dimension (FS) will show you the volume of public funds (e.g. taxes) or other local funds (e.g. from employers or households) compared to donor resources. This is important in countries where donors are channeling their resources through the government mechanisms and has not been visible before. The FS dimension will allow us to see their contribution to health expenditures in the country. The new GHED data will thus better describe the health financing system in each country and allow us to observe and measure the impact of different reforms, its impact on equity and access to health services. Only based on this data the cross-country comparison will be meaningful. An example of the benefits of the introduction of the dimension of source of health expenditure is the reflection of different sources of social health insurance schemes (SHI). Many countries that have SHI arrangements are using general revenues as a revenue source. However, there was no place to obtain systematic data on the relative magnitude of different funding sources for SHI because only expenditure by social health insurance agencies was reported. Under the source of health expenditure dimension it is possible to report SHI sources from SHI contributions and from government transfers. Health financing arrangements As financing healthcare differs among countries, it is important to find unifying features which will allow us comparing them to understand how countries move toward the goals of UHC. The systems where mandatory or automatic participation exists and individual risk of health costs are shared across the country constitute the Government and compulsory contributory schemes (HF.1). In such systems government ensures access to care for the whole or large part of the society based on prepaid contributions. In case participation in the program is voluntary and prepaid, we describe is as voluntary schemes (HF.2). Here individual are free to contribute or opt out at their own discretion but benefit from the availability of wider pool of resources. When people have to pay at the point of use directly for obtaining care they incur out of pocket payments (HF.3) which often constitutes a major barrier to access health care. High out-of-pocket payments can cause financial hardship and thus need to be closely monitored in all countries. Countries chose to mix these basic financing mechanisms, but they all can fit into these main categories and we can start comparing them and evaluate them on their path towards UHC. The new structure of health expenditure shifts attention to the principles of health financing such as the entitlement and cross-subsidization. The ownership or legal form of the insurance fund becomes irrelevant when exam whether people have to contribute to it, or have the choice to opt out. This helps 4

5 us in understanding systems with multiple agencies and programs with different eligibility criteria. When social health insurance is operated by private companies the principle of mandatory membership better reflects the position and benefits the people are enjoying from such scheme. 2. Health expenditure estimates Health expenditures for each country were assessed and mapped according to the SHA2011 framework, either by the source of funding (FS) or the financial arrangement (HF). Health expenditure estimates measure the final consumption expenditure by resident households of goods and services with the primary purpose of improving, maintaining and preventing the deterioration of their health status. Final consumption itself can be broken down into final consumption expenditure and investment (or gross capital formation). These boundaries of health and all estimation and classification details are based on the SHA2011 framework. Where possible, gross capital formation expenditures were reported in the capital account (HK). According to SHA2011, gross capital formation in health care is defined as the acquisition of produced assets; that is, assets intended for use in the production of other goods and services over a period of one year or more. It is the sum of the values of the following three components: Gross fixed capital formation; Changes in inventories; and Acquisitions less disposals of valuables. All capital expenditures, whenever identified, were recorded in the capital account (HK) and excluded from the estimates of current health expenditures (CHE). In some instances, gross capital formation could not be identified and certain estimates of CHE might also include capital expenditures as described in the metadata. All health expenditure estimates are otherwise thus based on CHE estimates, including all of the indicators except capital expenditure as a share of gross domestic product (HK%GDP). There are four main financing arrangements describing how health financing is organized and how countries mitigate the financial risk of the population when accessing healthcare. The main types of financing schemes are - Government schemes and compulsory contributory schemes (HF.1), Voluntary schemes (HF.2), Household out-of-pocket payment (HF.3) and Rest of the world (HF.4). HF.1 is further divided between Government schemes (HF.1.1) and Compulsory contributory health insurance schemes (HF.1.2) which includes Social health insurance schemes (HF.1.2.1) and Compulsory private insurance schemes HF Voluntary schemes (HF.2) are divided among Voluntary health insurance (HF.2.1), Non- Profit Institutions Serving Households or Non-profit institutions serving households (NPISH) including the expenditure of development agencies not channelled through government (HF.2.2) and Enterprise financing schemes (HF.2.3). All definitions can be found in the System of Health Accounts 2011 Manual 1 and its application for individual countries is described in the GHED metadata section for each data point published

6 Financing arrangements and schemes published in GHED HF Current health expenditure by financing schemes HF.1 - Government schemes and compulsory contributory health care financing schemes o HF Government schemes o HF Compulsory contributory health insurance schemes HF Social health insurance schemes HF Compulsory private insurance schemes o HF.1.3 Compulsory Medical Saving Accounts (CMSA) HF.2 - Voluntary health care payment schemes o HF Voluntary health insurance schemes o HF NPISH financing schemes (including development agencies) o HF Enterprise financing schemes HF.3 Household out-of-pocket payment HF.4 - Rest of the world financing schemes (non-resident) HF.nec Unspecified financing schemes To reflect the sources of health expenditure in each of the financing arrangements described above, the FS classification can be used. There are seven main sources of funds for healthcare which include Transfers from government domestic revenue (FS.1, such as Internal transfers and grants, FS.1.1.; Transfers by government on behalf of specific groups, FS.1.2; Subsidies, FS.1.3 and Other transfers from government domestic revenue, FS.1.4), Transfers distributed by government from foreign origin (FS.2), Social insurance contributions (FS.3), Compulsory prepayment (FS.4), Voluntary prepayment (FS.5), Other domestic revenues (FS.6, including from households, FS.6.1; corporations, FS.6.2; and non-profit institutions FS.6.3) and finally Direct foreign transfers (FS.7). Many financing schemes have usually only one source of funds (for example the HF.3 out of pocket payments are funded by revenues from households, FS.6.1) but there are also many examples of financing arrangements receiving revenues from several sources, such as social health insurance, which can be funded by social insurance contributions (FS.3), by transfers by government on behalf of specific groups (FS.1.2). To understand the complexities of the possible combination of sources and funds, a crossclassification and tabulation of the HFxFS in each country is ideal 2. As the information on sources of healthcare funds is published for the first time and without the cross tabulation with the scheme dimension, we decided to interpret the transfers by government on behalf of specific groups (FS.1.2) as 2 See for example the OECD Health Statistics 2017, which includes a table for several countries Revenues of health care financing schemes, 6

7 mainly government transfers to the Compulsory contributory health insurance schemes (HF.1.2), which in most countries means social health insurance. Sources of funding for financing schemes reported in the GHED FS Current health expenditure by revenues of health care financing schemes FS.1 - Transfers from government domestic revenue o FS.1.1 Internal transfers and grants o FS.1.2 Transfers by government on behalf of specific groups o FS.1.3 Subsidies o FS.1.4 Other transfers from government domestic revenue FS.2 Transfers distributed by government from foreign origin FS.3 Social insurance contributions FS.4 Compulsory prepayment FS.5 Voluntary prepayment FS.6 Other domestic revenues o FS.6.1 Other revenues from households o FS.6.2 Other revenues from corporations o FS.6.3 Other revenues from non-profit institutions o FS.6.nec Unspecified other domestic revenues FS.7 Direct foreign transfers FS.nec Unspecified revenues of health care financing schemes Methodological notes on health expenditure estimates The health expenditure estimates have been prepared under the framework of the System of Health Accounts 2011 and any detail of its application in individual countries can be seen in the country footnotes, the metadata and in this technical note. General information on the data: In countries where the fiscal year begins in July, expenditure data have been allocated to the later calendar year (for example, 2011 data will cover the fiscal year ) unless otherwise stated for the country. Absolute values of expenditures are expressed in nominal terms (current prices). Care needs to be taken in interpreting external resource figures. Most are taken from the OECD DAC/CRS database except where a reliable full Health Accounts study has been done. These are 7

8 disbursements to recipient countries as reported by donors, lagged one year to account for the delay between disbursement and expenditure. Disbursement data are not available prior to 2002 and commitments are used instead. General information on the presentation of the data: For health expenditure ratios, values smaller than 0.05% may appear as zero. For per capita indicators, when the value is less than 0.5 it is represented as < 1. National currency units per US$ are calculated using the average exchange rates for the year. Special Note: OECD countries data source is the Joint OECD, EUROSTAT and WHO Health Accounts SHA Questionnaires (JHAQ). All data on expenditure by financing arrangements come from the Joint questionnaire. Some expenditure by financing sources also come from the Joint questionnaire, or has been estimated by WHO in consultation with technical experts in that field. 3. Health expenditure indicators Health expenditure indicators help users, policy makers and other stakeholders to compare countries, monitoring progress towards UHC, evaluate impact of health reforms, and compare observe expenditure trends over time. The health expenditure indicators are calculated by dividing the health expenditure estimate (numerator) by some macroeconomic estimate or total current health expenditure (denominator), for example the share of current health expenditures of gross domestic product (GDP). There are 4 groups of indicators i) summary indicators, ii) indicators of sources of funds for health, iii) indicators describing financing arrangements and iv) cross-indicators, combining specific revenues of social health insurance. The summary indicators reflect overall health expenditures enabling comparison among countries in relation to their economic product (GDP) and population in comparable currency both of current and capital expenditures. This first group of indicators thus includes I. The size of the current health expenditure relative to the size of the economy in % (CHE%GDP) II. Investment into the health sector relative to the size of the economy in % (HK%GDP) III. Current health expenditures per capita in USD (CHE_pc_USD) IV. Current health expenditures per capita in PPP international dollars (CHE_cp_PPP) The indicators of sources of funds for health expenditure describe who funds healthcare in each country, and help us understand the role of external, domestic public and domestic private funding, which are the 3 main components of sources (FS) of healthcare expenditures. Taxes or mandatory contributions to health insurance represent public sources of health expenditures used to protect the population against financial hardship when accessing healthcare services. Voluntary prepayment and revenues from 8

9 household, corporations and non-profit institutions form the basis of domestic private sources for health. The health expenditure from external sources fund healthcare directly or are channeled through the government. These three components, external, private and public domestic expenditures, always add up to 100% of CHE. They can be also compared using per capita values in USD reflecting the size of each country and its population. This second group of indicators includes: V. Domestic Health Expenditures as % Current Health Expenditure (DOM%CHE) VI. Domestic General Government Health Expenditure as % Current Health Expenditure (GGHE-D%CHE) VII. Domestic Private Health Expenditure as % Current Health Expenditure (PVT-D%CHE) VIII. Health expenditure from external sources as % of Current Health Expenditure (EXT%CHE) Domestic Health Expenditures are composed of public and private domestic sources. The Domestic public sources include domestic revenue as internal transfers and grants, transfers, subsidies to voluntary health insurance beneficiaries, NPISH or enterprise financing schemes as well as compulsory prepayment and social health insurance contributions. All these transfers and subsidies represent public sources for health and indicate the overall governments contribution to funding healthcare relative to other sources of funding from domestic private and external sources. The indicator GGHE-D%CHE depicts the share of public health expenditures from the overall current health expenditure. The domestic private expenditure on health indicates how much health expenditure is funded domestically by the private expenditures on health. Private expenditures stem from households, corporations and non-profit organizations. Such expenditures can be either expenditures by voluntary health insurance or paid directly to healthcare providers. The indicator PVT-D%CHE describes the share of the private expenditure relative to the overall current health expenditure. The health expenditure from external sources summarizes how much is funded by resourced from official development aid and other external sources. External sources compose of direct foreign transfers and foreign transfers distributed by government encompassing all financial inflows into the health system from outside the country. The indicator EXT%CHE describes the share of the external expenditure relative to the overall current health expenditure. The following equations hold for all countries: CHE = DOM + EXT = GGHE-D + PVT-D + EXT 100% = DOM%CHE + EXT%CHE = GGHE-D%CHE + PVT-D%CHE + EXT%CHE Specific focus is devoted to the domestic public expenditures on health. Public expenditures on health include Transfers from government domestic revenue (FS.1), Social insurance contributions (FS.3) and Compulsory prepayment (FS.4). The share of public expenditures on health as a share of general government expenditures (GGHE-D%GGE) has become a tool to evaluate the priority each government gives to health. The definition of public expenditures on health (GGHE-D) differs from the GGHE used in other publications in two important aspects it only includes current government expenditures on health and domestic sources (i.e. it excludes capital investments and transfers distributed by government from foreign origin that were previously included in the former definition of GGHE). We expect the value of the 9

10 GGHE-D%GGE compared to GGHE%GGE to be lower and much more precise for health policy analysis purposes. Another indicator relevant for the policy-making is the share of public expenditures of the whole economy measured by gross domestic product (GDP). Please note that both denominators include not only current expenditures, but overall government expenditures and GDP. IX. Domestic General Government Health Expenditure as % General Government Expenditure (GGHE- D%GGE) X. Domestic General Government Health Expenditure as % Gross Domestic Product (GGHE-D%GDP) XI. Domestic General Government Health Expenditure per Capita in USD (GGHE-D_pc_USD) XII. Domestic General Government Health Expenditure per Capita in PPP international dollars (GGHE- D_pc_PPP) The share of domestic general government health expenditures of general government expenditure indicates the priority of the government to spend on health from own domestic public resources. It expresses this priority by comparing the size of current public health expenditures relative to the total size of government expenditure. The public expenditures on health per capita in USD/USDPPP calculate the average public expenditure on health per person in comparable currency. It contributes to understand the public expenditures on health relative to the population size facilitating international comparison. The indicator GGHE-D%GDP describes the share of public expenditures on health as a share of the economy as measured by GDP, indicating the fiscal space for health. Private Health Expenditure includes Voluntary prepayment (FS.5), and other revenues from households, corporations and non-profit institutions (FS.6). Beside the indicator mentioned above (PVT-D%CHE), there are two other indicators enabling international comparison of the size of the private expenditures on health: XIII. XIV. Domestic Private Health Expenditure per Capita in USD (PVT-D_pc_USD) Domestic Private Health Expenditure per Capita in PPP international dollars (PVT-D_pc_PPP) The private expenditures on health per capita in USD/USDPPP calculate the average public expenditure on health per person in comparable currency. It contributes to understand the private health expenditure relative to the population size facilitating international comparison. Countries that receive external resources to fund health may find relevant the indicators on the relative size of official development assistance expenditures on health (EXT%CHE) and what share of such external support is channeled through the government (EXT-G%EXT). Health expenditure from external sources includes transfers distributed by government from foreign origin (FS.2) and direct foreign transfers (FS.7). Beside the indicator mentioned above (EXT%CHE), there are three other indicators prepared for international comparison are: XV. XVI. External Health Expenditure Channeled through Government as % of External Health Expenditure (EXT-G%EXT) External Health Expenditure per Capita in US$ (EXT_pc_USD) 10

11 XVII. External Health Expenditure per Capita in PPP international dollars (EXT_pc_PPP) The share of current external health expenditures flowing through the government (EXT-G%EXT) reflects the cooperation and alignment of external funding with the government budget processes. External sources either flow through the domestic government scheme or is channeled through NGOs or other schemes, which are direct transactions between donors and local implementing partners. This indicator describes how the donors implement their projects and/or channel the financial flows in each country on budget. The indicator EXT-G%EXT calculates the share of external donor funding flowing through the government budgets relative to the overall external expenditures on health. The external expenditures on health per capita in USD/USDPPP calculate the average external expenditure on health per person in comparable currency. It contributes to understand the external health expenditure relative to the population size facilitating international comparison The third group of indicators describe financing arrangements and are based on the HF classification. They reflect how countries pool funds and mandate the participation within health insurance schemes as protection mechanisms against financial hardship when accessing healthcare services. There are either compulsory financing arrangements (CFA) or voluntary financing arrangements (VFA) which include out of pocket payments, voluntary health insurance and other voluntary schemes. CFAs include and are further disaggregated into government financing arrangements (GFA) and compulsory health insurance (CHI). Social health insurance (SHI) is the most common type of CHI and is reported as a separate indicator. VFAs include voluntary health insurance (VHI), out of pocket payments (OOP) and other financing arrangements (OTHER). The following equation holds for all countries: CHE = CFA + VFA = (GFA + CHI) + (VHI + OOP + OTHER) The indicators of financing arrangements are either calculated as shares of CHE or in per capita in USD PPP XVIII. Share of compulsory financing arrangements of Current Health Expenditure (CFA%CHE) XIX. share of government financing arrangements of Current Health Expenditure (GFA%CHE ) XX. share of compulsory health insurance of Current Health Expenditure (CHI%CHE) XXI. Share of social health insurance of Current Health Expenditure (SHI%CHE) XXII. Share of voluntary financing arrangements of Current Health Expenditure (VFA%CHE) XXIII. Share of voluntary health insurance of Current Health Expenditure (VHI%CHE) XXIV. Share of out of pocket payments of Current Health Expenditure (OOP%CHE) XXV. Share of other voluntary financing arrangements of Current Health Expenditure (OTHER%CHE) XXVI. Share of compulsory financing arrangements of General Government Expenditures (CFA%GGE) XXVII. Compulsory Financing Arrangements per Capita in US$ (CFA_pc_USD) XXVIII. Compulsory Financing Arrangements per Capita in PPP international dollars (CFA_pc_PPP) XXIX. Voluntary Financing Arrangements per Capita in US$ (VFA_pc_USD) 11

12 XXX. XXXI. XXXII. Voluntary Financing Arrangements per Capita in PPP international dollars (VFA_pc_PPP) Out-of-Pocket Expenditure per Capita in US$ (OOP_pc_USD) Out-of-Pocket Expenditure per Capita in PPP international dollars (OOP_pc_PPP) The CFA%CHE indicator estimates how much each country spends on health through compulsory financing arrangement relative to the overall health expenditure. This indicator shows the share of prepaid pooled resources from mandatory systems of total current health expenditures. Compulsory financing arrangements include government schemes and compulsory insurance mechanisms such as social health insurance. The GFA%CHE indicator estimates how much each country spends on health through government financing arrangement. This indicator shows the share of pooled resources from non-contributory mandatory systems of total current health expenditures. The CHI%CHE indicator estimates how much each country spends on health through compulsory health insurance as a share of overall health expenditures. This indicator shows the share of mandatory prepaid pooled resources of contributory health insurance schemes, such as social health insurance and other compulsory health insurance schemes. The SHI%CHE indicator estimates how much each country spends on health through social health insurance as a share of current health expenditures. This indicator shows the share of prepaid pooled resources of social health insurance schemes of current health expenditures. The VFA%CHE indicator estimates how much each country spends on health through voluntary financing arrangement. This indicators shows the share of resources from schemes where membership or participation is not mandatory of current health expenditures. Voluntary financing arrangements include out of pocket payments, voluntary health insurance, NPISH, out of pocket payments, enterprise schemes and other schemes where participation is not mandatory by law, including external donor funding. The VHI%CHE indicator estimates how much each country spends on health through voluntary health insurance. This indicators shows the share of resources from prepaid health insurance schemes where membership or participation is voluntary of current health expenditures. The OOP%CHE indicator estimates how much are households in each country spending on health directly out of pocket as a share of current health expenditures. The OTHER%CHE indicator estimates how much each country spends on health through other voluntary financing arrangements then out of pocket, and voluntary health insurance. It estimates the share of NPISH and enterprise health expenditures of total current health expenditures. The CFA%GGE indicator estimates how much each country spends on health through compulsory financing arrangement as a share of general government expenditures. This indicator shows the share of prepaid pooled resources from mandatory financing arrangements (see above the definition of CFA) of total general government expenditures. 12

13 The CFA, VFA and OOP indicators are also estimates in indicators as expenditure per person in comparable currency. These indicators contribute to our understanding of the compulsory, voluntary and out of pocket health expenditure relative to the population size facilitating international comparison. The last group of indicators combines the sources of revenues of financing arrangements and specifically analyses the revenues of social health insurance from government transfers. It currently includes only one indicator assessing the role of government transfers as a sourced of social health insurance expenditures. XXXIII. Government Budget Transfers to Social Health Insurance as % of Social Health Insurance (SHI- G%SHI) This indicator shows the share of expenditures by social health insurance scheme funded from government transfers. It indicates the level of subsidization of contributory schemes from government general sources such as taxes, usually done on behalf of specific populations. The indicator facilitates international comparison by exposing the structure of revenues of social health insurance schemes. 13

14 Annex calculation of indicators using the SHA2011 classification Indicator Name Abbreviation Numerator and Denominator Current Health Expenditure (CHE) as % Gross Domestic Product (GDP) CHE%GDP CHE/GDP Capital Health Expenditure (HK) as % Gross Domestic Product (GDP) HK%GDP HK/GDP Current Health Expenditure (CHE) per Capita in US$ CHE_pc_US$ CHE in USD / population Current Health Expenditure (CHE) per Capita in PPP Int$ CHE_pc_PPP CHE in USD PPP / population Indicator Name Abbreviation Numerator and Denominator Domestic Health Expenditure (DOM) as % of Current Health Expenditure (CHE) DOM%CHE (FS.1 + FS.3+FS.4+FS.5+FS.6)/CHE Domestic General Government Health Expenditure (GGHE-D) as % Current Health Expenditure (CHE) GGHE-D%CHE (FS.1 + FS.3 + FS.4)/CHE Domestic Private Health Expenditure (PVT-D) as % Current Health Expenditure (CHE) PVT-D%CHE (FS.5 + FS.6)/CHE Health Expenditure from External Sources (EXT) as % of Current Health Expenditure (CHE) EXT%CHE (FS.2 + FS.7)/CHE Domestic General Government Health Expenditure (GGHE-D) as % General Government Expenditure (GGE) GGHE-D%GGE (FS.1 + FS.3 + FS.4)/GGE Domestic General Government Health Expenditure (GGHE-D) as % Gross Domestic Product (GDP) GGHE-D%GDP (FS.1 + FS.3 + FS.4)/GDP External Health Expenditure Channeled through Government (EXT-G) as % of External Health Expenditure (EXT) EXT-G%EXT FS.2/(FS.2 + FS.7) Domestic General Government Health Expenditure (GGHE-D) per Capita in GGHE- US$ D_pc_US$ (FS.1 + FS.3 + FS.4)/population Domestic General Government Health Expenditure (GGHE-D) per Capita in GGHE- PPP Int$ D_pc_PPP (FS.1 + FS.3 + FS.4)/population Domestic Private Health Expenditure (PVT-D) per Capita in US$ PVT-D_pc_US$ (FS.5 + FS.6)/population Domestic Private Health Expenditure (PVT-D) per Capita in PPP Int$ PVT-D_pc_PPP (FS.5 + FS.6)/population Health Expenditure from External Sources (EXT) per Capita in US$ EXT_pc_US$ (FS.2 + FS.7)/population Health Expenditure from External Sources (EXT) per Capita in PPP Int$ EXT_pc_PPP (FS.2 + FS.7)/population 14

15 Indicator Name Abbreviation Numerator and Denominator Compulsory Financing Arrangements (CFA) as % of Current Health Expenditure (HF1.1 + CFA%CHE (CHE) HF1.2+HF.1.3+HF.4.1)/CHE Government Financing Arrangements (GFA) as % of Current Health Expenditure (CHE) GFA%CHE HF1.1/CHE Compulsory Health Insurance (CHI) as % of Current Health Expenditure (CHE) CHI%CHE ( HF1.2 + HF HF.4.1)/CHE Social Health Insurance (SHI) as % of Current Health Expenditure (CHE) SHI%CHE HF.1.2.1/CHE Voluntary Financing Arrangements (VFA) as % of Current Health Expenditure (CHE) VFA%CHE (HF.2 + HF.3 + HF.4.2)/CHE Voluntary Health Insurance as % of Current Health Expenditure (CHE) VHI%CHE (HF2.1 + HF.4.2)/CHE Out-of-Pocket Expenditure (OOP) as % of Current Health Expenditure (CHE) OOP%CHE HF3/CHE Other Financing Arrangements as % of Current Health Expenditure (CHE) OTHER%CHE (HF HF.2.3)/CHE Compulsory Financing Arrangements (CFA) as % of General Government (HF1.1 + HF1.2+ HF CFA%GGE Expenditure (GGE) HF.4.1)/GGE Compulsory Financing Arrangements (CFA) per Capita in US$ CFA_pc_US$ (HF1.1 + HF1.2 + HF HF.4.1)/population Compulsory Financing Arrangements (CFA) per Capita in PPP Int$ CFA_pc_PPP (HF1.1 + HF1.2 + HF HF.4.1)/population Voluntary Financing Arrangements (VFA) per Capita in US$ VFA_pc_US$ (HF2 + HF.3 + HF.4.2)/population Voluntary Financing Arrangements (VFA) per Capita in PPP Int$ VFA_pc_PPP (HF2 + HF.3 + HF.4.2)/population Out-of-Pocket Expenditure (OOP) per Capita in US$ OOP_pc_US$ (HF.3)/population Out-of-Pocket Expenditure (OOP) per Capita in PPP Int$ OOP_pc_PPP (HF.3)/population 15

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