Improving estimates of international trade in health services under A System of Health Accounts

1. Improving estimates of international trade in health services under A System of Health Accounts Working Party on International Trade in Goods and Trade in Services Statistics November 7-9, 2011, PARIS

2. Background Key definition of health expenditure in SHA: • Includes health care goods and services provided to residents by non-resident providers • Excludes goods and services provided to non-residents by resident providers • Past experience – poorly reported, no explicit reporting of services provided to non-residents, insufficient guidelines, data sources • Growing importance in recent years • Significant for some countries • Need to better define, measure and monitor

3. Cross-border Health Care in the EU EU Directive • Respect patients’ rights to seek healthcare abroad while preserving rights for states to manage healthcare systems • Reimbursed for treatment if entitled to in own country • Prior authorisation only for ‘hospital’ care • Covers prescription and medical goods (excl. LTC and organ transplants) • Information on safety, quality and tariffs • Monitoring (flows and financing) - EC Regulation 1338/2008

4. OECD Trade in Health project • 2 year project supported by EU • First phase 2009/2010 • review of concepts and boundaries • links to existing frameworks (BPM6, MSITS, TSA) • country case studies (regulations, sources, recommendations) – DEU, GRC, HUN, KOR, SVN, USA • Second phase 2010/2011 • Draft framework, definitions, guidelines. • Workshop and feasibility testing • Final report • Parallel with SHA Revision (Chapter 12 on Int. Trade)

5. Basic Concepts and Definitions Balance of Payments (BPM6/SNA08) as basis: • Economic territory – national, supra-national, sub-national • Residence and non-residence – households and providers - Residence vs. covered population • Valuation • Consistent with SHA basic concepts (Follow SNA) • Exporting vs. importing countries valuation (in kind) • Timing • Accrual basis • Reporting delays

6. Existing Classifications and Links • Mode of supply of trade in services (WTO/GATS) • (1) Cross-border supply , (2) consumption abroad, (3) commercial presence (outside SHA), (4) foreign persons (partial SHA) • MSITS/EBOPs classification: • International statistics responding to BoP and GATS • ‘Health-related travel’ and ‘Health services’ close to SHA definitions • Tourist Statistics/TSA • Consumption of visitors with ‘health/medical’ purpose • Provides some common concepts and definitions/ sources

7. Health Services under EBOPS 2010 4 Travel • 4.2 Personal • 4.2.1 Health-related • 4.2.2 Education-related • 4.2.3 Other 11 Personal, cultural and recreational services • 11.2 Other personal, cultural and recreational services • 11.2.1 Health services Alternative EBOPS groupings 8 Health services = health services in travel + health services in personal, cultural and recreational services Plus: Other direct insurance Business services Other personal, cultural and recreational services n.i.e.

8. SHA Concept of Trade Import for ‘ intermediate use ’ by Health care resident provider provider in Country A Health care provider in Country B Resident in Import for ‘ final use ’ Country A b y resident

9. Imports and Exports under SHA Health care goods and services classified according to health care functions • Personal health care : • Medical goods • internet pharmacies, mail order • Tele-medicine, e-health, etc • Patient mobility : planned, unplanned care (tourists, students, workers, etc) • Health professionals abroad • Collective care : • Health care insurance • Outsourcing of governance, administration, etc

10. Borderline Issues • Cosmetic surgery – for aesthetic purposes • Well-being/Spas – health-related item • Illegal / unethical treatments • Transport and travel costs – accompanying persons/agency costs • ‘Health-y’ goods • Health professionals (temporary)

11. Guidelines for Estimating Trade • Current reporting limited but improving • Common sources with BoP/SNA/TSA – detail/ adjustments needed • Improvement of measurement of mutual benefit • Inventory of current/potential sources • Weigh up investment in resources / new sources with perceived value of trade in health • Review in light of national and international obligations

12. Data Sources • Business surveys - administrative/ad hoc • Government administrative data – budgetary, social security funds, liaison offices • Private insurance records • Household and tourist surveys • Associations and other bodies – insurance, NGOs • Other sources - mirror statistics, non-financial data, modelling. • Other BoP data sources – ITS, ITRS, etc

13. Reporting and Supplementary Tables • Imports included - cross-classified by Function and Financing • non-resident providers of health goods and services (HP.9) • Supplementary tables • ‘Imports’ (HC.I.1-7) broken down by Financing scheme (HF) • ‘Exports’ (HC.E.1-7) broken down by resident provider • Memorandum items • TCAM, Spa/well-being (non-health), Non-health, etc • Other country specific breakdowns • Mode of supply, trading partners, population groups, patient numbers, etc

14. SHA 2011: Chapter 12 • Background and Policy Relevance • Basic concepts and definitions • Classifications of trade (in health) and links to other statistical systems • Imports and exports under SHA • Data sources and Guidelines • Reporting and Supplementary tables

15. Current Reporting: Imports 2009 2004-2009

16. Current Reporting: Exports 2009 2004-2009

17. For further information: www.oecd.org/health/sha