Summary
This document is destined to the countries’ teams in charge of the elaboration of health accounts studies and provides methodological guidance to track and classify, within SHA health accounts, coronavirus disease 2019 (COVID-19) health expenditure and related expenditure according to the System of Health Accounts (SHA 2011) framework. The present technical note is based on the discussions within the International Health Accounts Team (IHAT, including WHO, OECD and Eurostat) and health accounts experts that resulted in the development of guidance notes for the OECD, Eurostat and WHO Joint Health Accounts Questionnaire on tracking health expenditure related to COVID-19 (2,3). Based on this guidance for OECD countries and EU countries and the piloting data collection in 2021, WHO extended the recommendations to the context of low and middle income countries and countries producing health accounts by disease based on standard health accounts procedures from SHA 2011 and related guidance documents and health accounts experts’ opinion.
It is recommended that Member states governments, and in particular health accounts teams, follow these recommendations and clarification of SHA 2011 rules in the context of COVID-19 when they elaborate their health accounts studies, in order to report and provide a consistent measure of COVID-19 health expenditure, that could be comparable in time and between countries.
The general methodological framework is presented in Chapter 1. The main point is while the COVID-19 may have a significant impact on health spending since 2020, the pandemic does not change the fundamental accounting principles on which the SHA 2011 is based. General SHA accounting rules and guidelines still apply to current health expenditure on COVID-19 (primary intent of the activity to improve, maintain or prevent the deterioration of the health; qualified health knowledge and skills; consumption for final use of the resident population; existence of a transaction). Many actions related to the response to COVID-19 are therefore outside of the scope of SHA 2011 and of this technical note: quarantine compliance costs, social measures linked to the pandemic, etc. or other economic impacts of the pandemic not measured as expenditure, such as income loss from business closures, supply chain disruptions, etc. Several borderline cases and boundary issues exist nonetheless, and are discussed in this document: for example, spending on personal protective equipment (PPE) as intermediate consumption or for final use (to be included in current health spending), compliance costs in businesses (excluded from CHE), activities accounted as occupational health care (included in CHE), costs of quarantine (only medical costs and quarantine in health facilities are accounted as CHE), transfers to health care provider (should be specifically targeted to health providers to be registered as subsidy under CHE), etc.
For specific reporting of COVID-19 expenditure, the present document recommends the use of the DIS.1.9.2 category in the classification of diseases and conditions (DIS) under outbreaks declared as Public Health Emergency of International Concern (PHEIC, DIS.1.9). In addition, IHAT in the JHAQ 2021 and WHO in the HAQ 2021 introduced in their data collection templates a number of special memorandum items for COVID-19 spending (HC.COV for current health expenditure, including 5 categories of notification HC.COV.1 to HC.COV.5,
HK.COV for capital expenditure related to COVID-19 and HCR.COV for spending of interest outside the boundaries of CHE). The use of these memorandum items is recommended in the context of the COVID-19 pandemic, at least for countries which do not report the DIS classification. COVID-19 memorandum items provide additional information for international data reporting, but in principle, current health expenditure recorded under DIS.1.9.2 should be equal to HC.COV (Sum of HC.COV.1, HC.COV.2, HC.COV.3, HC.COV.4, HC.COV.5).
Chapter 2 is focusing on data collection, which is a key step of health accounts studies that will determine the comprehensiveness of the health financing flows reported. Therefore, it is important as a first step to clearly identify new financing flows created during the COVID-19 pandemic and new data sources available. Then, within all the data sources used for health accounts, several might be helpful to specifically identify health spending related to COVID-19: among others, government budget data and budget execution of the COVID-19 Strategic Preparedness and Response Plan (SPRP), external donors’ surveys, households’ surveys, and utilisation, morbidity / mortality data used to build distribution keys by diseases.
After data collection, Chapter 3 present guidance for mapping COVID-19 health expenditure to SHA 2011 categories: in particular, Table 4 provides recommendation for mapping activities to the HC classification (and to HC.COV memorandum items), such as activities of public health / governance (HC.6 and HC.7), testing (HC.1,
HC.4 and HC.6 according to the settings), contact tracing (HC.6), treatments (HC.1), medical goods, including PPE, for final use (HC.5 or accounted implicitly as intermediate consumption), immunization (HC.6.2), etc. For other SHA classifications, the mapping might be straight forward, but the document also provides specific recommendations for the HP classification (among other to correctly map HP by the primary activity of the provider and not by the place where whe service was provided), the FP classification and the DIS classification.
Finally, Chapter 4 presents data reporting templates: for the elaboration of health accounts studies and reports of health expenditure data for the Global Health Expenditure Database (GHED) update, countries are encouraged to use the Health Accounts Production Tool (HAPT). As an alternative to HAPT, WHO Member states can use the WHO Health Accounts Questionnaire (HAQ) to report COVID-19 memorandum items by financing scheme (HF), health care providers (HP), revenues (FS) and DIS classification by revenues. The chapter also includes a short selection of indicators that might be useful to analyse the importance of COVID-19 expenditure in countries.
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