oecd · 2018. 3. 1. · table 1. (cont.) functional classification in the icha (icha-hc function...

STD/NA/RD(98)5

OECD

Organisation de Coopération et de Développement EconomiquesOrganisation for Economic Co-operation and Development

OCDE

STATISTICS DIRECTORATE

National Accounts

OECD MEETING OF NATIONAL ACCOUNTS EXPERTS

Château de la Muette, Paris22-25 September 1998Beginning at 9.30 a.m. on the first day

Agenda item: 12

A system of health accounts for international datacollection, Part II: Draft International Classification forHealth Accounts (ICHA)

OECD

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A SYSTEM OF HEALTH ACCOUNTSFOR INTERNATIONAL DATA COLLECTION

PART II. DRAFT INTERNATIONAL CLASSIFICATION FOR HEALTH ACCOUNTS (ICHA)

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TABLE OF CONTENTS

CHAPTER 8. FUNCTIONAL CLASSIFICATION OF MEDICAL CARE................................................. 4

Introduction................................................................................................................................................. 4Functions of personal medical care ............................................................................................................ 7Curative, rehabilitative and long-term nursing care ................................................................................... 7Modes of production ................................................................................................................................... 7HC.1 Services of curative care ................................................................................................................... 9HC.2 Services of rehabilitative care ......................................................................................................... 12HC.3 Services of long-term nursing care ................................................................................................. 13HC.4 Ancillary services to medical care .................................................................................................. 15HC.5 Dispensing medical goods to out-patients....................................................................................... 16HC.6 Prevention and public health services ............................................................................................. 19HC.7 Health programme administration and health insurance................................................................. 22HC.R. Health-related functions ................................................................................................................ 23Annex 1. Further boundary problems of medical care ............................................................................. 29Annex 2. Cross-classifying the functional classification with other international classifications .......... 32Annex 3. Cross-classification of WHO “Essential Public Health Functions” (EPHFs) with the

public health functions in the ICHA-HC and COFOG............................................................ 35

CHAPTER 9. CLASSIFICATION OF MEDICAL CARE INDUSTRIES.................................................. 37

HI.1 Hospitals ........................................................................................................................................... 40HI.2 Nursing and residential care facilities .............................................................................................. 42HI.3 Ambulatory health care .................................................................................................................... 45HI.4 Retail sale and other providers of medical goods............................................................................. 52HI.5 Provision and administration of public health programmes............................................................. 54HI.6 General health administration and insurance ................................................................................... 54HI.9 All other industries ........................................................................................................................... 56Annex. Cross-classification of ICHA-HI with ISIC, NACE and NAICS ................................................ 57

CHAPTER 10. CLASSIFICATION OF MEDICAL CARE FINANCING................................................. 58

Territorial government .............................................................................................................................. 59Social insurance and social security schemes........................................................................................... 60

REFERENCES AND BIBLIOGRAPHY..................................................................................................... 64

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Tables

Table 1. Functional classification in the ICHA (ICHA-HC function component) ..................................... 5Table 2. Maternal and child health in the ICPM ...................................................................................... 20Table 3. Selected environmental health functions .................................................................................... 27Table 4. Health-related cash benefits........................................................................................................ 28Table 5. Cross-classification of ICHA-HC, COFOG and COICOP......................................................... 33Table 6. Cross-classification of EPHFs, ICHA-HC, and COFOG ........................................................... 35Table 7. ICHA-Classification of institutions in medical care .................................................................. 39Table 8. Cross-classification of ICHA-HI with ISIC classes ................................................................... 57Table 9. ICHA-Classification of medical care financing ......................................................................... 60

Boxes

Box 1. Sub-acute care ............................................................................................................................... 12Box 2. Treatment of expenditures for teaching hospitals ......................................................................... 24Box 3. Basic definitions of R&D.............................................................................................................. 25Box 4. The borderline between specialised health care and R&D ........................................................... 26Box 5. Social insurance schemes .............................................................................................................. 61Box 6. Social security schemes................................................................................................................. 62Box 7. Out-of-pocket payments and cost-sharing by private households. ............................................... 62

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CHAPTER 8. FUNCTIONAL CLASSIFICATION OF MEDICAL CARE

Introduction

1. The one-digit level of the functional classification (presented in Chapter 2) is extended in thisChapter by items at the two- and the three-digit level complemented by explanatory notes. Thedevelopment of a fine structure of functions of medical care is, however, still experimental. Theexact contents and meaning of sub-categories as well as the precision of defining them maychange over time, when improved versions of the basic classifications will become available andwill be more widely applied in a larger number of countries. A number or further breakdowns ofmedical care is recommended under various functions of personal care according to theadditional dimension of reporting sketched in Chapter 2.

2. The following procedural classifications were used in the design of the ICHA functionalcomponent:

• ICD-9-CM: International Classification of Disease, Clinical Modification

• ICPM: International Classification of Procedures in Medicine;

• IC-Process-PC: International Classification of Primary Care, Process Component.

3. Annex 1 to this Chapter discusses selected boundary issues of medical care. Cross-classifications of the ICHA-HC with other international classifications are provided in Annex 2and Annex 3 to foster the reconciliation of health accounting with other data collection, notablywith the System of National Accounts and its accompanying classifications.

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Table 1. Functional classification in the ICHA (ICHA-HC function component)

ICHAcode

Function of medical care

HC.1 Services of curative care

HC.1.1 In-patient curative careHC.1.2 Day cases of curative careHC.1.3 Out-patient curative care

HC.1.3.1 Basic medical and diagnostic servicesHC.1.3.2 Medical mental health and substance abuse therapyHC.1.3.3 Ambulatory surgical proceduresHC.1.3.4 Out-patient dental careHC.1.3.5 All other specialised medical servicesHC.1.3.9 All other out-patient curative care

HC.1.4 Services of curative home care

HC.2 Services of rehabilitative care

HC.2.1 In-patient rehabilitative careHC.2.2 Day cases of rehabilitative careHC.2.3 Out-patient rehabilitative careHC.2.4 Services of rehabilitative home care

HC.3 Services of long-term nursing care

HC.3.1 In-patient long-term nursing careHC.3.1.1 In-patient long-term nursing care for dependent elderly patientsHC.3.1.2 In-patient long-term nursing care for mental health and substance

abuse patientsHC.3.1.3 All other in-patient long-term nursing care

HC.3.2 Day cases of long-term nursing careHC.3.2.1 Day cases of long-term nursing care for dependent elderly patientsHC.3.2.2 All other day cases of long-term nursing care

HC.3.3 Long-term nursing care: home careHC.3.3.1 Long-term nursing care: home care for dependent elderly patientsHC.3.3.2 Long-term nursing care: all other home care

HC.4 Ancillary services to medical care

HC.4.1 Clinical laboratoryHC.4.2 Diagnostic imagingHC.4.3 Patient transport and emergency rescueHC.4.9 All other miscellaneous ancillary services

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Table 1. (cont.) Functional classification in the ICHA (ICHA-HC function component)

ICHAcode

Function of medical care

HC.5 Dispensing medical goods to out-patients

HC.5.1 PharmaceuticalsHC.5.1.1 Prescribed medicinesHC.5.1.2 Over-the-counter medicines

HC.5.2 Therapeutic appliances and medical equipmentHC.5.2.1 Glasses and other vision productsHC.5.2.2 Orthopaedic appliances and other prostheticsHC.5.2.3 Hearing aidsHC.5.2.4 Medico-technical devices, including wheelchairsHC.5.2.9 All other miscellaneous medical goods

HC.6 Prevention and public health services

HC.6.1 Maternal and child health; family planning and counsellingHC.6.2 School health servicesHC.6.3 Prevention of communicable diseasesHC.6.4 Prevention of non-communicable diseasesHC.6.5 Occupational health careHC.6.9 All other miscellaneous public health services

HC.7 Health programme administration and health insurance

HC.7.1 General government administration of health programmes and policiesHC.7.1.1 Territorial government general administration of health programmes

and policiesHC.7.1.2 Administration, operation and support activities of social security

schemes covering health servicesHC.7.2 Health programme administration and health insurance: private

HC.7.2.1 Health programme administration and health insurance: socialinsurance

HC.7.2.2 Health programme administration and health insurance: other private

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Table 1. (cont.) Functional classification in the ICHA (ICHA-HC function component)

ICHA code Health-related functions

HC.R.1 Education and training of health personnelHC.R.2 Research and development in healthHC.R.3 Food, hygiene and drinking water controlHC.R.4 Environmental healthHC.R.5 Administration and provision of social services in kind to assist living with disease

and impairmentHC.R.6 Administration and provision of health-related cash-benefits

Explanatory notes

Functions of personal medical care

4. Functions of personal medical care comprise functions HC.1 to HC.5. These are services and goodsthat can be directly allocated to individuals as distinct from services provided to society at large(HC.6, Prevention and public health services; and HC.7, Health programme administration andhealth insurance). Functions of personal medical care are both classified by basic functions of care(curative, rehabilitative and long-term nursing care) and by mode of production (in-patient, daycare, out-patient, home care).

Curative, rehabilitative and long-term nursing care

5. The basic criteria for classifying medical care services is the type of episode of care provided(curative, rehabilitative and long-term nursing care). Definitions developed by the AustralianHealth Data Committee, and by the US Joint Commission on Accreditation of HealthcareOrganizations (JCAHO) have been adopted as a model and have been modified only slightly for usein a larger group of countries.

Modes of production

6. The following definitions of mode of production are used throughout the ICHA-HC classificationfor defining categories of personal medical services at the two-digit level.

In-patient care

7. An in-patient is a patient who is formally admitted (or “hospitalised”) to an institution fortreatment and/or care and stays for a minimum of one night in the hospital or other institutionproviding in-patient care. In-patient care is delivered in hospitals, other nursing and residential carefacilities or in establishments which are classified according to their focus of care under theambulatory care industry but perform in-patient care as a secondary activity. Included are servicesdelivered to in-patients in prison and army hospitals, tuberculosis hospitals, and sanatoriums. In-

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patient care includes accommodation provided in combination with medical treatment when thelatter is the predominant activity provided during the stay as an in-patient.

8. Providing patients and patients’ relatives with accommodation is considered an integral part of in-patient care. The hotel function of hospital care becomes apparent when patients are transferred topost-acute hospital wards or “hostels” providing less intensive and limited medical care but whichare functionally integrated in the provision of hospital care.

9. A stay in “hotel wards” is part of the therapeutic course and warrants to be recorded under totalexpenditure on health. This includes the hosting of patients’ relatives whose presence is anindispensable part of therapy, for example in the case of severe treatment episodes of children, inparticular those performed in highly specialised hospitals far away from the patient’s hometown.(In the case of developing countries, which are not the primary focus of this manual, the (imputedand actual) cost of services performed by patients’ relatives in hospitals - including cooking, basicnursing care, and cleaning - would be included under this heading).

10. On the other hand, accommodation in institutions providing social services, where medical care isan important but not predominant component should not be included in the health function.Examples might include institutions such as homes for disabled persons, nursing homes, andresidential care for substance abuse patients.

Day care

11. Day care comprises medical and paramedical services delivered to patients that are formallyadmitted for diagnosis, treatment or other types of medical care with the intention of dischargingthe patient on the same day. An episode of care for a patient who is admitted as a day care patientand subsequently stays over night is classified as an overnight stay or other in-patient case.Services for non-admitted patients that are extended to formal admission for day care areconsidered as day care. A day patient (or “same-day patient”) is usually admitted and thendischarged after staying between 3 and 8 hours on the same day.

Out-patient care

12. This item comprises medical and paramedical services delivered to out-patients. An out-patient isnot formally admitted to the facility (physician’s private office, hospital out-patient centre orambulatory care centre) and does not stay over night. An out-patient is thus a person who goes to ahealth care facility for a consultation/treatment, and who leaves the facility within several hours ofthe start of the consultation without being “admitted” to the facility as a patient.

Home care

13. This item comprises medical and paramedical services delivered to patients at home. It excludesthe consumption of medical goods (pharmaceuticals, other medical goods) dispensed to out-patientsas part of private household consumption.

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14. This item comprises medical and paramedical services delivered during an episode of curative care.An episode of curative care is one in which the principal clinical intent is one or more of thefollowing:

− to manage labour (obstetric);

− to cure illness or provide definitive treatment of injury;

− to perform surgery;

− to relieve symptoms of illness or injury (excluding palliative care);

− to reduce severity of an illness or injury;

− to protect against exacerbation and/or complication of an illness and/or injury which couldthreaten life or normal function;

− to perform diagnostic or therapeutic procedures.

Source: adopted from Australian Health Data Committee (1997)

HC.1.1 In-patient curative care

15. In-patient curative care comprises medical and paramedical services delivered to in-patients duringan episode of curative care for an admitted patient.

16. Includes: overnight stays. During an overnight stay, in-patients leave the hospital or otherinstitutions the day following the day of admission but usually not less than twelve hours afteradmission.

Note

17. This item is further disaggregated in the SHA by ICD and DRG groups (where available, seeChapter 2).

HC.1.2 Day cases of curative day care

18. Services of curative day care comprise medical and paramedical services delivered to day-carepatients during an episode of curative care such as ambulatory surgery, dialysis, and oncologicalcare.

19. Includes: ambulatory surgery day care, which is all invasive therapies provided, under general orlocal anaesthesia, to day-care patients whose post-surveillance and convalescence stay requires noovernight stay as an in-patient. Surgical procedures are defined according to national lists ofprocedures. For countries using ICD-9-CM coding (International Classification of Diseases,Clinical Modification), surgical procedures are defined by the codes 01 to 86. Ambulatory surgery

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procedures constitute a subclass of surgery amenable to ambulatory care. Other classifications usedare the Nordic Surgical Classification and the Office of Population Census and Surveys (OPCS)(UK).

HC.1.3 Out-patient curative care

20. Services of out-patient curative care comprise medical and paramedical services delivered to out-patients during an episode of curative care. Out-patient medical care comprises services deliveredto out-patients by physicians in establishments of the ambulatory health care industry or out-patientdepartments of establishments of the hospital industry. Out-patients may be treated inestablishments of the hospital industry, for example in out-patient wards.

HC.1.3.1 Basic medical services

21. This item comprises services of medical diagnosis and therapy that are common components ofmost medical encounters and that are provided by physicians to out-patients. These include routineexaminations, medical assessments, prescription of pharmaceuticals, routine counselling of patients,dietary regime, injections and vaccination (only if not covered under public health preventionprogrammes). They can be part of initial medical attention and consultation or of follow-upcontacts. Routine administrative procedures like filling in and updating patients’ records areusually an integral part of basic medical services.

22. Excludes: home visits by general practitioners and primary care physicians; paramedical servicesprescribed by physicians and performed under their own responsibility by paramedicalprofessionals, either in their own practice or in a setting affiliated with physicians, or grouppractices.

Note

23. Basic medical services are distinct from more specialised services in that they can typically beperformed without using highly sophisticated medical equipment. In addition, they exclude most ofthe medical services that are typically performed by para-medical personnel. Basic medicalservices are defined independently of whether they are performed by a family doctor or a specialist.When medical records do not allow for a separation of activities by physicians into the componentsdefined under HC.1.3, a separation of services according to professions should be used as a firstapproximation.

24. Most items under Section 5 (Therapeutic Procedures) and many of the items of Section 8(Clinical and Administrative Services) of the IC-Process-PC fall under this category. Exceptionsto this rule are: physical therapy (IC-Process-PC, 55), reproductive and urologic systemprocedures (56), obstetrical procedures (57) and psychological counselling/assessment andhealth education (82, 84).

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HC.1.3.2 Medical mental health and substance abuse therapy

25. This item comprises out-patient medical curative care provided by physicians to mental health andsubstance abuse patients where the focus of care is procedures related to the psyche as defined bythe list provided in ICD-9-CM, code 94. Services provided to mental health and substance abusepatients comprises special mental treatment and training (performed by medical or paramedicalpersonnel) psychotherapy, psychosocial treatment, pedagogic diagnostics, pedagogic training,orthodidactic diagnostics. The service is provided by a trained specialist (doctor, psychologist)predominantly performing psychological encounters and therapy.

HC.1.3.3 Ambulatory surgical procedures

26. This item comprises all invasive therapies provided, under general or local anaesthesia, to out-patients whose post-surveillance and convalescence stay requires no overnight stay and no formaladmission as an in-patient. Surgical procedures are defined according to national lists of procedures(the note on ambulatory surgery under HC.1.2 applies correspondingly).

HC.1.3.4 Out-patient dental care

27. This item comprises dental medical services (including dental prosthesis) provided to out-patientsby physicians. It includes the whole range of services performed usually by medical specialists ofdental care in an out-patient setting such as tooth extraction, fitting of dental prosthesis and dentalimplants.

Note

28. Dental prostheses are treated in the SHA as intermediate products to the production of services ofdental care and thus always included under expenditure on dental care.

HC.1.3.5 All other out-patient specialised curative medical care

29. This item comprises all other specialised medical services provided to out-patients by physicians(other than mental health and substance abuse therapy, ambulatory surgery, and dental care).

HC.3.1.9 All other paramedical out-patient curative care

30. This item comprises all other miscellaneous medical and paramedical services provided to out-patients by physicians or paramedical practitioners. Included are services provided to out-patientsby paramedical professionals such as chiropractors, occupational therapists, and audiologists.Included is paramedical mental health and substance abuse therapy, such as speech therapy. Thisitem includes paramedical traditional medical services.

31. Includes: diagnostic physical therapy, physical therapy exercise and other therapeutical procedures,such as hydrotherapy and heat therapy; orthotic and prosthetic care; attention to wounds;osteopathic treatment; speech therapy; training and medical rehabilitation for the blind.

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HC.1.4 Curative medical home care

32. This item comprises all medical and paramedical curative services provided to patients at home.

Note

33. This includes highly specialised services such as home dialysis. In many cases home care isprovided in combination with social services such as homemaking or meals on wheels whichshould, however, be recorded separately as they are not part of expenditure on health.

HC.2 Services of rehabilitative care

34. This item comprises medical and paramedical services delivered to patients during an episode ofrehabilitative care for an admitted patient.

35. Services of rehabilitative care comprise services where the emphasis lies on improving thefunctional levels of the persons served and where the functional limitations are either due to arecent event of illness or injury or of a recurrent nature (regression or progression). Included areservices delivered to persons where the onset of disease or impairment to be treated occurred furtherin the past or has not been subject to prior rehabilitation services.

36. An episode of rehabilitative care corresponds to sub-acute care as it has been defined by the USJoint Commission on Accreditation of Healthcare Organizations (JCAHO):

Box 1. Sub-acute care

Sub-acute care is treatment rendered immediately after, or instead of, acute hospitalisation to treat oneor more specific active complex medical conditions or to administer one or more specific activecomplex medical treatments, in the context of a person’s underlying long-term conditions and overallsituation.

Generally, the individual’s condition is such that the care does not depend heavily on high-technologymonitoring or complex diagnostic procedures. It requires the co-ordinated services of aninterdisciplinary team including physicians, nurses, and other relevant professional disciplines, whoare trained and have the knowledge to assess and manage the specific in-patient care designed forsomeone who has had an acute illness, injury, or exacerbation of a disease condition, and to performnecessary procedures.

Subacute care is generally more intensive than traditional nursing facility care and less than acute(curative) care. It requires frequent (daily to weekly) recurrent patient assessment and review of theclinical course and treatment plan for a limited (several days to several months) time period, until acondition is stabilised or a pre-determined treatment course is completed.

Source: adapted from JCAHO

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HC.2.1 Services of in-patient rehabilitative care

37. This item comprises medical and paramedical services delivered to in-patients during an episode ofrehabilitative care for an admitted patient.

HC.2.2 Services of rehabilitative day care

38. This item comprises medical and paramedical services delivered to day-care patients during anepisode of rehabilitative care for a day-care patient.

HC.2.3 Services of out-patient day care

39. This item comprises medical and paramedical services delivered during an episode of rehabilitativecare to out-patients.

HC.2.4 Services of rehabilitative home care

40. This item comprises medical and paramedical services delivered to patients at home during anepisode of rehabilitative care.


41. Long-term medical care delivered to in-patients comprises ongoing medical care given to in-patients who need assistance on a continuing basis due to chronic impairments and a reduced degreeof independence and activities of daily living. In-patient long-term care is provided in institutionsor community facilities. Long-term care is typically a mix of medical and social services.

HC.3.1 In-patient long-term nursing care

42. This item comprises nursing care delivered to in-patients who need assistance on a continuing basisdue to chronic impairments and a reduced degree of independence and activities of daily living. In-patient long-term nursing care is provided in institutions or community facilities. Long-term care istypically a mix of medical and social services. Only medical services are recorded in the SHAunder personal medical services.

HC.3.1.1 In-patient long-term nursing care for dependent elderly patients

43. Long-term medical care for dependent elderly patients comprises continuing nursing care providedto in-patients of age 65 and over who need assistance on a continuing basis due to chronicimpairments and a reduced degree of independence and activities of daily living. This includesrespite care and care provided in homes for the aged by specially trained persons, where medicalnursing care is an important component. This type of care can be provided in combination withsocial services which should, however, be recorded separately as they are not part of expenditure onhealth.

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HC.3.1.2 In-patient long-term nursing care for mental health and substance abuse patients

44. This item comprises ongoing medical care given to in-patients who are below the age of 65 andneed assistance on a continuing basis due to chronic impairments and a reduced degree ofindependence and activities of daily living that are due to chronic or recurrent psychiatricconditions. The focus of care is procedures related to the psyche as defined by the list provided inICD-9-CM, code 94.

HC.3.1.3 All other in-patient long-term nursing care

45. This item comprises ongoing medical care given to in-patients other than mental health andsubstance abuse patients, who are below the age of 65, and need assistance on a continuing basisdue to chronic impairments and a reduced degree of independence and activities of daily living.

46. Includes: hospice care (medical, paramedical and nursing care services to the terminally ill,including the counselling for their families). Hospice care is usually provided in nursing homes orsimilar specialised institutions.

HC.3.2 Day cases of long-term nursing care

47. This item comprises nursing care delivered to day cases of patients who need assistance on acontinuing basis due to chronic impairments and a reduced degree of independence and activities ofdaily living. Day-care nursing care is provided in institutions or community facilities.

HC.3.2.1 Day cases of long-term nursing care for dependent elderly patients

48. This item comprises nursing care delivered to day-care patients of age 65 and over who needassistance on a continuing basis due to chronic impairments and a reduced degree of independenceand activities of daily living. In-patient long-term nursing care is provided in institutions orcommunity facilities. Long-term care for dependent elderly patients is typically a mix of medicaland social services. Only medical services are recorded in the SHA under personal medicalservices.

HC.3.2.2 All other day cases of long-term nursing care for dependent elderly patients

49. This item comprises nursing care delivered to day-care patients under the age of 65 who needassistance on a continuing basis due to chronic impairments and a reduced degree of independenceand activities of daily living. Long-term nursing care is provided in institutions or communityfacilities. Long-term care is typically a mix of medical and social services. Only medical servicesare recorded in the SHA under personal medical services.

HC.3.3 Long-term nursing care: home care

50. This item comprises ongoing paramedical care provided at home to dependent elderly patients ofage 65 and over who need assistance on a continuing basis due to chronic impairments and areduced degree of independence and activities of daily living. This type of home care can include

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social services such as homemaking and meals on wheels which should, however, be recordedseparately as they are not part of expenditure on health.

HC.3.3.1 Long-term nursing care: home care for dependent elderly patients

51. Long-term medical care for dependent elderly patients comprises continuing nursing care providedat home to patients of age 65 and over who need assistance on a continuing basis due to chronicimpairments and a reduced degree of independence and activities of daily living. This includesrespite care and care provided at home by specially trained persons, were medical nursing care is animportant component. This type of care can be provided in combination with social services whichshould, however, be recorded separately as they are not part of expenditure on health.

HC.3.3.2 Long-term nursing care: all other home care

52. This item comprises all other long-term nursing care provided at home to dependent patients agedunder 65 who need assistance on a continuing basis due to chronic impairments and a reduceddegree of independence and activities of daily living.


53. This item comprises a variety of services, mainly performed by paramedical or medical technicalpersonnel with or without the direct supervision of a medical doctor, such as laboratory, diagnosisimaging and patient transport.

HC.4.1. Clinical laboratory

54. This item covers the following services provided to out-patients common in clinical laboratory:urine, physical and chemical tests, blood chemistry, automated blood chemistry profiles,haematology, immunology, faeces, microbiological cultures, microscopic examination, specialisedcytology and tissue pathology, all other miscellaneous laboratory tests.

Note

55. This list is based on agreements reached under ICPM and IC-Process-PC, and comprises thefamilies of clinical and pathology tests as listed in the IC-Process-PC (IC-Process-PC, 1986,Section 2). An alternative list is provided by ICD-9-CM: 90 Microscopic examination-I, 91Microscopic examination-II.

HC.4.2. Diagnostic imaging

56. This item comprises diagnostic imaging services provided to out-patients.

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Note

57. Diagnostic imaging comprises the following items described in the ICD-9-CM procedurecomponent: 87 Diagnostic radiology, 88 Other diagnostic radiology and related techniques. Thecorresponding sub-headings given in the IC-Process-PC (IC-Process-PC, 1986, Section 3) are:Plain X-ray, bone; Soft tissue imaging, plain (excluding nuclear scanning, nuclear magneticresonance, ultrasound); Contrast X-rays or photo-imaging; Computerised tomography and nuclearmagnetic imaging; Nuclear scanning; Diagnostic ultrasound; All other miscellaneous diagnosticimaging (arteriography using contrast material, angiocardiography, phlebography, thermography,bone mineral density studies).

HC.4.3 Patient transport and emergency rescue

58. This item comprises transportation in a specially-equipped surface vehicle or in a designated airambulance to and from facilities for the purposes of receiving medical and surgical care. It alsoincludes transportation in conventional vehicles, such as taxi, when the latter is authorised and thecosts are reimbursed to the patient (as is often the case for patients undergoing renal dialysis orchemotherapy). Emergency transport includes emergency transport services of public fire rescuedepartments or defence that operate on a regular basis for civilian emergency services (not only forcatastrophe medicine).

HC.4.9 All other miscellaneous ancillary services to medical care

59. This item comprises all other miscellaneous ancilliary services to medical care, such astelemedicine.


60. This item comprises medical goods dispensed to out-patients and the services connected withdispensing, such as retail trade, fitting, maintaining, and renting of medical goods and appliances.Included are services of public pharmacies, opticians, sanitary shops, and other specialised or non-specialised retail traders including mail ordering and tele-shopping.

Note

61. The group of goods covered is essentially the products listed in the (draft) Classification ofIndividual Consumption by Purpose (COICOP) under 06.1 - Medical products, appliances andequipment.

62. This group covers medicaments, prostheses, medical appliances and equipment and other healthrelated products provided to individuals, either with or without a prescription, usually fromdispensing chemists, pharmacists or medical equipment suppliers intended for consumption or useby a single individual or household outside a health facility or institution.

63. With COICOP being a one-dimensional classification, not primarily designed for the purposes ofHealth Accounting, a different regrouping was chosen for the proposed ICHA-HC.

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64. Renting and repair of therapeutic appliances and equipment is reported under the correspondingcategories of goods. Also included is the service of dispensing medical goods, fitting of prosthesesand services like eye tests, in those cases where these services are performed by specially trainedretailed traders and not by medical professions. Following COICOP recommendations, thefollowing items are excluded: protective goggles, belts and supports for sport; veterinary products;sun-glasses not fitted with corrective lenses; medicinal soaps. The COICOP classifies all themedical products listed above as non-durables, whereas in several national health accounts,"Durable medical goods" are distinguished from consumable or disposable products.

65. Excludes: pharmaceuticals, prostheses, and other medical and health-related goods supplied to in-patients and day care patients or products delivered to out-patients as part of treatment providedwithin the facilities of ambulatory care.

HC.5.1 Pharmaceuticals

66. This item comprises pharmaceuticals such as medicinal preparations, branded and genericmedicines, drugs, patent medicines, serums and vaccines, vitamins and minerals and oralcontraceptives.

Note

67. Vitamins might be taken in many (or most) instances without a medical indication, or prescriptionand are beyond the control of doctors and pharmacies. Vitamins are, however, complex chemicalsubstances, that, when abused, can be harmful -- like other drugs. The common practice to sell andconsume vitamins like normal food products, thus not recording them as outlays, is debatable.Included is the pharmacist’s remuneration when the latter is separate from the price of medicines.The expenditure includes VAT and sales taxes where applicable (valuation at purchaser’s prices).

HC.5.1.1 Prescribed medicines

68. Prescribed medicines are medicines, exclusively sold to customers with a medical voucher,irrespective of whether it is covered by public or private funding and include branded and genericproducts. In the SHA, this includes the full price with a breakdown for cost-sharing.

HC.5.1.2 Over-the-counter medicines

69. Over-the-counter medicines (OTC medicines) are classified as private households pharmaceuticalexpenditure of non-prescription medicines.

Note

70. Non-prescription medicines are often called over-the-counter (OTC) perhaps as they may beincluded in physician prescriptions, though not reimbursed.

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HC.5.2 Therapeutic appliances and medical equipment

71. This item comprises a wide range of medical goods including the distribution for final use of allother medical goods besides pharmaceuticals.

HC.5.2.1 Glasses and other vision products

72. This item comprises corrective eye-glasses and contact lenses as well as the correspondingcleansing fluid. Also included is the fitting by opticians.

HC.5.2.2 Orthopaedic appliances and other prosthetics

73. This item comprises orthopaedic appliances and other prosthetics; orthopaedic shoes, artificiallimbs and other prosthetic devices, orthopaedic braces and supports, surgical belts, trusses andsupports, neck braces.

HC.5.2.3 Hearing aids

74. This item comprises all kinds of removable hearing aids (including cleaning, adjustment andbatteries).

75. Excludes: audiological diagnosis and treatment by physicians (HC.1.3.5); implants (HC.1.1 in-patient curative care); audiological training (HC.1.3.9).

HC.5.2.4 Medico-technical devices, including wheelchairs

76. This item comprises a variety of medico-technical devices such as wheelchairs (powered andunpowered) and invalid carriages.

HC.5.2.9 All other miscellaneous medical product

77. This item comprises a wide variety of miscellaneous medical products not elsewhere classified suchas: blood pressure instruments, clinical thermometers, adhesive and non-adhesive bandages,hypodermic syringes, first-aid kits, condoms, incontinence material, hot-water bottles and ice bags,medical hosiery items such as elastic stockings and knee pads. These goods are included as theymay constitute an important cost component in homecare, in particular when caring for dependentelderly persons. Excluded however, are automatic staircase lifts.

Note

78. The above list corresponds to recommendations in the latest COICOP draft (OECD, 1998b).

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HC.6 Prevention and public health services

79. Prevention and public health services comprise services designed to enhance the health status of thepopulation as distinct from the curative services which repair health dysfunction. Typical servicesare vaccination campaigns and programmes.

Note

80. Prevention and public health functions included in the ICHA-HC do not cover all fields of publichealth in the broadest sense of a cross-functional common concern for health matters in all politicaland public actions. Some of these broadly defined public health functions such as emergency plans,and environmental protection, are not part of expenditure on health. The most important of thesepublic health functions are classified under various Health related functions in the ICHA-HC.Some public health functions which represent strategic principles of a cross-functional nature couldnot be allocated to certain sub-functions of public or private. A cross-classification of public healthfunctions according to a broad WHO list of Essential public health functions (EPHFs) with ICHA-HC and COFOG is provided in Annex 3.

HC.6.1 Maternal and child health; family planning and counselling

81. Maternal and child health covers a wide range of medical services such as genetic counselling andprevention of specific congenital abnormalities, prenatal and postnatal medical attention, babyhealth care, pre-school and school child health, and vaccinations.

Note

82. In COFOG, Family planning services are not classified under health (draft COFOG function 07) butunder Family and Children (draft COFOG 10.4.0). For health accounting it is recommended thatthese services be reallocated under the above defined health function. An illustration of the rangeof activities covered under this item is provided by the following cross-classification with ICPM.

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Maternal and child health in the ICPM

ICPM code Description

4.20 Prenatal screening investigation4.21 Neonatal screening for abnormality4.22 Other infancy screening examination4.23 Childhood screening examination

(4-60 to 4.72) Maternal and child health care

4.60 Initial ambulatory medical attention, current pregnancy4.61 Initial medical ambulatory attention after delivery4.62 Subsequent medical ambulatory, current pregnancy4.63 Public health nurse (prenatal/postnatal care)4.65 Contraceptive procedures4.66 Eugenic procedures4.67 Child medical guidance4.69 Participation in other health activities of maternal and child care4.70 Premature care at home4.71 Well-baby health care4.72 Pre-school child health care

Source: ICPM (1972, Chapter 4)

HC.6.2 School health services

83. This item comprises a variety of services of health education and screening (for example, bydentists), disease prevention, and the promotion of healthy living conditions and lifestyles providedin school. This includes basic medical treatment if provided as an integral part of the public healthfunction, such as dental treatment.

84. Includes: interventions against smoking, alcohol and substance abuse

85. Excludes: vaccination programmes (HC.6.3)

HC.6.3 Prevention of communicable diseases

86. This item comprises compulsory reporting and notification of certain communicable diseases andepidemiological enquiries into communicable disease; efforts to trace possible contacts and originof disease; prevention of tuberculosis and tuberculosis control (including systematic screening ofhigh risk groups); immunisation/vaccination programmes (compulsory and voluntary); vaccinationunder maternity and child health care.

87. Excludes: vaccination for occupational health (HC.6.5); vaccination for travel and tourism on thepatients’ own initiative (HC.1.3.1).

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HC.6.4 Prevention of non-communicable diseases

88. This item comprises public health services of health education, disease prevention, and thepromotion of healthy living conditions and lifestyles such as services provided by centres fordisease surveillance and control; and programmes for the avoidance of risks incurred and theimprovement of the health status of nations even when not specifically directed towardscommunicable diseases.

89. Includes: interventions against smoking, alcohol and substance abuse such as anti-smokingcampaigns; activities of community workers; services provided by self-help groups; generalhealth education and health information of the public; health education campaigns; campaigns infavour of healthier life-styles, safe sex etc.; information exchanges: e.g. alcoholism, drug addiction.

90. Excludes: public health environmental surveillance and public information on environmentalconditions.

Note

91. Health promotion and disease prevention presents a difficult boundary issue for which nointernational classification exists. The boundaries drawn in national health accounts are usuallylinked to the identification of specific programmes of screening and health check-ups with a legallyor administratively defined, limited coverage reimbursed separately under public or private healthschemes. Examples are screening of blood pressure, diabetes, certain forms of cancer, dentalhealth, and “health check-ups”.

92. Prevention is in many instances a reason for encounter and not a separate procedure. This meansthat the same procedure (for example, many diagnostic procedures) can be either performed aspreventive measures for screening purposes or as diagnostic procedures in the case of an acutehealth problem. The criterion for including services under this item is whether prevention isprovided as a social programme (public or private, including occupational health) or is requested onthe patient’s own initiative.

HC.6.4 Occupational health care

93. Occupational health care comprises a wide variety of health services such as surveillance ofemployee health (routine medical check-ups) and therapeutic care (including emergency medicalservices) on or off-business premises (including government and non-profit institutions servinghouseholds). This excludes, however, remuneration-in-kind of health services and goods whichconstitute household actual final consumption rather than intermediate consumption of business.

Note

94. Occupational health care (HC.5.4) corresponds to item 5.2: Health in the draft outline of a revisedClassification of Outlays of Producers by Purpose (COPP, Revision 1) applied to intermediateconsumption of producers. Occupational health care is an intermediate consumption within thebusiness sector.

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95. Occupational health care is only part of a broader range of activities that aim at improving theworking environment in its relation to health. Occupational health activities to improve ergonomy,safety and health and environmental protection at the workplace, accident prevention, etc., shouldbe distinguished from occupational health care. They are not to be recorded under medical careactivities.

HC.6.9 All other miscellaneous public health services

96. This item comprises a variety of miscellaneous public health services such as operation andadministration of blood and organ banks, and the preparation and dissemination of information onpublic health matters not classified elsewhere.

Includes: public health environmental surveillance and public information on environmental conditions.

HC.7 Health programme administration and health insurance

97. Health programme administration and health insurance are activities of private insurers and centraland local authorities, and social security schemes. Included is the planning, management,regulation, collection of funds and handling of claims of the delivery system.

HC.7.1 General government administration of health programmes and policies

HC.7.1.1 Territorial government general administration of health programmes and policies

98. This item comprises a variety of activities of overall government administration of health thatcannot be assigned to HC.1 to HC.6; activities such as formulation, administration, co-ordinationand monitoring of overall health policies, plans, programmes and budgets (draft COFOG, code07.6).

99. Includes: preparation and enforcement of legislation and standards for the provision of healthservices, including the licencing of medical establishments and medical and para-medicalpersonnel; production and dissemination of general information, technical documentation andstatistics on health (other than those classified under HC.6, Prevention and public health).

100. Excludes: compilation of health statistics by a central statistical agency (draft COFOG, code 01,General Public Services; administration of public security; law and order activities; fire serviceactivities; defence activities; road traffic control (draft COFOG, code 03, Public Order and Safety).

HC.7.1.2 Administration of social security schemes covering health services

101. This item comprises the administration, operation and support of social security schemes coveringhealth services. Social security schemes are defined in Chapter 6 and 9 on the financing of healthcare.

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HC.7.2 Health programme administration and health insurance: private

HC.7.2.1 Health programme administration and health insurance: social insurance

102. This item comprises the administration and operation of private non-profit social health insurance.Private non-profit insurance schemes are defined in Chapter 6 and 9 on the financing of health care.

HC.7.2.2 Health programme administration and health insurance: other private insurance

103. This item comprises the administration and operation of all other private health and accidentinsurance including private for-profit insurance schemes (as defined in Chapter 6 and 9 on thefinancing of health care).

HC.R. Health-related functions

HC.R.1 Education and training of health personnel

104. This item comprises government and private provision of education and training of healthpersonnel, including the administration, inspection or support of institutions providing educationand training of health personnel. This corresponds to post-secondary and tertiary education in thefield of health (according to ISCED-97 code) by central and local government, and privateinstitutions such as nursing schools run by private hospitals.

Note

105. If properly accounted for, education and training of health personnel is not an overlapping functionbetween health and education. In teaching hospitals, for example, it would be desirable to haveseparate budgets for care provided, R&D, and for training. Where detailed accounts are missing,statistical practice as designed for UNESCO/OECD/Eurostat data collections on education andtraining are an alternative option (UNESCO/OECD/Eurostat, 1995).

106. A questionnaire on the basis of the International Standard Classification of Education (ISCED) wasjointly developed by UNESCO/OECD/Eurostat and data on educational finance are regularlycollected according to a common framework (OECD, 1995e). The proposed standard practice forsurveys of education and training is documented in the UNESCO ISCED-manual (InternationalStandard Classification of Education) and in the guidelines for the joint UNESCO/OECD/EurostatData Collection on Education Statistics.

107. Education and training of health personnel takes place mainly at ISCED-levels 5 (Non-university-degree tertiary level) to 7 (University tertiary level of education, leading to a second or furtheruniversity degree or equivalent). The following institutions are involved:

• Paramedical Schools (ISCED 5);

• Undergraduate Schools in medical/paramedical departments (ISCED 6);

• Graduate Schools in medical/biomedical departments (ISCED 7).

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108. Medical education and training corresponds in the list of fields of study (at the tertiary level ofeducation) provided by the ISCED manual (UNESCO, 1996) to the category Medical scienceand health-related (ISCED code 50). It should be noted that the ISCED Manual, furthermore,has a category Health-related auxiliary programmes (ISCED 50) at the upper secondary level ofeducation for vocational and technical programmes.

109. Complete costs would include expenditures for universities and other training institutions.Salaries of medical interns and residents or trainee nurses are reported under expenditure onhealth, for the services rendered. The training expenditures are also reported in the educationalaccounts. The intent of this category is to include expenditures for training that are closelylinked to the care of patients into medical services rather than into expenditure on education andtraining.

110. The following recommendation for university hospitals is taken from theUNESCO/OECD/Eurostat manual. Education and training of medical care personnel and themeasurement of human resources devoted to medical care, in general, are dealt with in Annex 2.

Box 2. Treatment of expenditures for teaching hospitals

Expenditures of or for teaching hospitals (sometimes referred to as academic hospitals or universityhospitals) should not be included in education expenditures, except to the limited extent that theyare directly and specifically related to the training of medical personnel. In particular, all costs ofpatient care other than general expenses of academic hospitals should be excluded from theeducation figures, even if such expenses must be paid by the education authorities.

Expenditures for research in academic hospitals should also be excluded, except that no attemptshould be made to distinguish between the research and non-research portions of the time ofteaching staff whose compensation is otherwise considered part of education expenditures.

Source: UNESCO/OECD/Eurostat (1995)

HC.R.2 Research and development in health

111. This item comprises R&D in health according to the following definition:

“R&D programmes directed towards the protection and improvement of human health. Itincludes R&D on food hygiene and nutrition and also R&D on radiation used for medicalpurposes, biochemical engineering, medical information, rationalisation of treatment andpharmacology (including testing medicines and breeding of laboratory animals for scientificpurposes) as well as research relating to epidemiology, prevention of industrial diseases anddrug addiction”

Source: Frascati Manual, OECD 1994d, p. 122.

Note

112. Government involvement in health R&D is classified in the draft COFOG as part of the healthfunction (draft COFOG, 07.5.1 R&D Health).

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113. The Frascati Manual on the Measurement of Scientific and Technological Activities (OECD,1994d) provides detailed definitions of R&D in business and government activities, including non-profit institutions and institutions of higher education. The Frascati Manual is the joint product ofnational experts on R&D in OECD Member countries, the OECD Secretariat and other internationalorganisations. These guidelines are consistent with UNESCO recommendations.

114. The Frascati Manual discusses boundary problems between R&D, education, and medical care andother industries providing guidelines for standard reporting in these and other fields, drawing theboundary line distinguishing the field from medical care and from education and training of healthpersonnel. Box 3 provides the basic definitions of R&D.

Box 3. Basic definitions of R&D

Research and experimental development (R&D) comprise creative work undertaken on a systematicbasis in order to increase the stock of knowledge, including knowledge of man, culture and societyand the use of this stock of knowledge to devise new applications.

R&D covers three distinct activities: basic research, applied research and experimentaldevelopment. Basic research is experimental or theoretical work undertaken primarily to acquirenew knowledge of the underlying foundation of phenomena and observable facts, without anyparticular application or use in view. Applied research is also original investigation undertaken inorder to acquire new knowledge. It is, however, directed primarily towards a specific practical aimor objective. Experimental development is systematic work, drawing on existing knowledge gainedfrom research and/or practical experience that is directed to producing new materials, products ordevices, to installing new processes, systems and services, or to improving substantially thosealready produced or installed.

Source: Frascati Manual (OECD 1994d, p. 29)

115. The basic criterion for distinguishing R&D form related activities is; "the presence in R&D of anappreciable element of novelty and the resolution of scientific and/or technological uncertainty, i.e.when the solution to a problem is not readily apparent to someone familiar with the basic stock ofcommonly used knowledge and techniques in the area concerned." "... a) In the field of medicine,routine autopsy on the causes of death is simply the practice of medical care and not R&D; specialinvestigation of a particular mortality in order to establish the side effects of certain cancertreatments is R&D. Similarly, routine tests such as blood and bacteriological tests carried out fordoctors, are not R&D but a special programme of blood tests in connection with the introduction ofa new drug is R&D." Frascati Manual (OECD 1994d, p. 33).

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116. The following recommendation from the Frascati Manual on R&D statistics should be adopted forthe collection of health care statistics.

Box 4. The borderline between specialised health care and R&D

In university hospitals where, in addition to the primary activity of health care, the training ofmedical students is of major importance, the activities of teaching, R&D and advanced as well asroutine medical care are frequently very closely linked. "Specialised medical care" is an activitywhich normally is to be excluded from R&D. However, there may be an element of R&D in whatis usually called "advanced medical care", carried out, for example, in university hospitals. It isdifficult for university doctors and their assistants to define that part of their overall activities whichis exclusively R&D. If, however, time and money spent on routine medical care are included in theR&D statistics, there will be an over-estimate of R&D resources in the medical sciences. Usuallysuch advanced medical care is not considered R&D and all medical care not directly linked to aspecific R&D project should be excluded from the R&D statistics.

Source: Frascati-Manual (OECD 1994d, p. 37)

117. R&D in health, when measured according to the rules of the Frascati Manual, excludes outlays bypharmaceutical firms, shown separately. For data collection on R&D, international standards exist.More details on data collection and international standards for reporting in R&D are documented inthe Frascati Manual (OECD, 1994d).

118. Activities of R&D in health care should exclude all education and training of health personnel inuniversities and special institutions of higher and post-secondary education. However, research bypostgraduate students carried out at universities and university hospitals in medical sciences shouldbe counted, wherever possible, as part of R&D in health care. R&D outlays by pharmaceuticalfirms have to be distinguished from other related scientific and technological activities (FrascatiManual, p. 30-33), such as, for example, patent and licence work.

HC.R.3 Environmental health and control of drinking water

119. This item comprises a variety of activities of a public health concern that are part of other publicactivities such as inspection and regulation of various industries and water supply.

120. This item comprises a wide variety of activities of public health concern that are part of other publicactivities such as environmental protection, control of drinking water, and food hygiene control.

Note

121. Activities under this item are part of various COFOG functions (draft COFOG, 04 EconomicAffairs (various industries); and 06.3 Water supply; Supervision and regulation of water purity).Lacking an agreed link to international standard definitions for Environmental health, it issuggested that it should comprise various items under COFOG function 05 Environment Protection.A list of such health-related functions is given in the following table.

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Table 2. Selected environmental health functions

COFOG code COFOG function Examples of "Environmental health" itemscovered

05 Environment protection

05.1 Waste management Safety measures and monitoring of healthhazards connected to these services

05.2 Waste water management Safety measures and monitoring ofenvironmental standards or other quality norms

05.3 Pollution abatement Activities relating to the prevention, monitoring,abatement and control of noise and the pollutionof air, water bodies and soil

05.5 R&D in environmental protection R&D in public health issues of environmentalprotection

05.6 Environmental protection n.e.c Production and dissemination of publicinformation about health risks associated withenvironmental situation

Source: COFOG, 1998 draft (OECD, 1998a)

122. The control of environmental hazards, in particular water and sewage treatment, have been amongthe important determinants of population health. In the second half of the 20th century, there aresigns of improvements as well as of decline of the environmental situation in OECD countries. Airpollution abatement, used water treatment, the disposal or recycling of solid waste have importantspill-over effects on health. However, from a theoretical point of view, environmental health doesnot constitute a health care function as it is not distinct from other public functions such as generalpublic safety, or law-and-order which all contribute to the enhancement of population health status.

123. In many countries, the responsibility for environmental health does not usually lie with Ministriesof Health. Separate accounting systems, such as satellite systems for environmental accounting,have been installed in many OECD countries for monitoring societies’ resources devoted toenvironmental protection as well as for estimating and evaluating improvements or declines in theenvironment. For international comparisons, a set of consistent indicators showing expenditurefunctions of environmental protection (including water supply) relevant for population health,would be a valuable complement of a system of Health Accounts.

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HC.R.4 Administration and provision of social services in kind to assist living with disease andimpairment

124. This item comprises (non-medical) social services in kind provided to persons with health problemsand functional limitations or impairments where the primary goal is the social and vocationalrehabilitation or integration.

125. Includes: Education of bed-bound children and special schooling for the handicapped (ICD-9-CM,93.82); occupational therapy (ICD-9-CM, 93.83); vocational rehabilitation and shelteredemployment (ICD-9-CM, 93.85).

Note

126. The provision of medical care benefits in kind under social protection arrangements is in somecases closely interwined with the provision of social benefits in kind to assist living with diseaseand medical impairment.

HC.R.6 Administration and provision of health related cash-benefits

127. This item comprises the administration and provision of health-related cash benefits by socialprotection schemes in the form of transfers provided to individual persons and households.Included are collective services such as the administration and regulation of these programmes.

Note

128. The provision of medical care benefits in kind under social protection arrangements is in somecases closely interwined with the provision of social protection in the form of transfers (cashbenefits) to individual persons and households. The COFOG and the European System ofintegrated Social Protection Statistics (ESSPROS) use the list of social protection functions shownin the following table together with examples of health-related benefits.

Table 3. Health-related cash benefits

COFOG code Social protection function Examples of health-related cash benefits

10.1.1 Sickness (see below)10.1.2 Disability Disability benefits10.1.3 Old age Health-related early retirement10.1.4 Family and children Maternity leave10.5.0 Unemployment Vocational rehabilitation10.6.0 Housing and social

exclusionMedical care benefits to homeless people

Source: COFOG, 1998 draft (OECD, 1988a), ESSPROS MANUAL (1996).

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The Sickness function refers to the;

Provision of social protection in the form of cash benefits that replace in whole or in part loss ofearnings during a temporary inability to work due to sickness or injury; administration andoperation of such social protection schemes.

Includes: benefits in kind provided to help persons temporarily unable to work due to sickness orinjury with daily tasks (home help, transport facilities, etc.)

Source: COFOG, draft 1998 (OECD, 1988a)

129. It is recommended to show under function HC.R.7 most payments falling under the Sicknessfunction. The remaining items should be seen as a list of examples to be used in checking if cashbenefits other than Sickness benefits are covered by health programmes (which is often the case fortraditional social insurance countries with a historically grown complex mix of services covered by“health insurance”). It would be desirable that, for Health Accounting, these supplementarybenefits be shown separately in order to interpret aspects of financing (such as contribution rates)correctly and to give sufficient detail on this in metadata to data collections.

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ANNEX 1. FURTHER BOUNDARY PROBLEMS OF MEDICAL CARE

1. Besides the detailed guidelines for the structure and boundary of the medical care functions HC.1 toHC.5 given below, the following recommendations reflect on common principles of drawingboundaries pointing at difficult issues for discussion.

The borderline between medical care and other social services

2. National Health Accounts draw different borderlines between medical care and other social servicesand comprise grey areas when social services involve a significant but not dominant medical carecomponent in long-term care for dependent elderly people. This may be the case in home care,other forms of institutional care, such as protective custody in mental health institutions, homes andprotected working places for disabled persons, and rehabilitation programmes for drug addicts.

3. The ground rule should be to report institutional care under medical care where institutionalisationis necessary for the person’s health or where the medical care component in question is mostefficiently provided in an institutional setting. For other forms of care, where the medicalcomponent is important but not dominant (less than half of the total cost), a medical carecomponent could be separated by estimating genuine medical care resources by evaluating theirinput in the form of labour and (intermediate) or final use of medical goods. Only labour input ofmedical professions performing medical functions (in the sense of the ICHA functional component)would be counted as a first approximation. In these cases, the accommodation function in theseinstitutions would be excluded from the medical care function.

4. Non-medical components (in the above sense) of occupational and other rehabilitation programmes,with the goal of retraining and social and occupational integration, should not be reported as healthexpenditure. Spa therapy sessions for mainly medical and curative purposes should bedistinguished from spa sessions for recreation or rehabilitation.

The borderline between medical care and other privately consumed personal services

5. There is an emerging medical care market for private patients in the form of packages combiningmedical services with non-medical personal services, notably tourism and recreational services suchas beauty care. Other patients may travel to foreign countries to buy expensive high quality caresuch as dental prostheses and dental implants, or spas for the cure of certain chronic illnesses inregions of the world that are especially successful in the provision of these services. For HealthAccounting, only the medical care component is included in the health function.

6. It is more difficult to determine whether first class services such as office equipment in acute carehospitals should be included in the health function. It is recommended that this kind of services beestimated as a separate item in a breakdown of hospital production by line items.

The borderline between medical care and other medical interventions

7. The application of medical knowledge and technology pursued not for purposes of cure and reliefbut in the form of interventions aiming at enhancing human mental or physical capacity beyondnatural limits or for other non-medical goals, may pose puzzling boundary issues in the future

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(besides the ethical questions involved that society has to address). Cosmetic surgery unrelated tothe reconstruction of traumatic damages, in-vitro fertilisation, and brain chips for other thanmedical-therapeutical or diagnostic purposes fall into this category. Doping and the intake ofsteroids in body building are other well-known examples.

8. At the moment, health statistics usually include these services as well as every other form of legalmedical intervention on humans performed by licensed health professionals. Thus, the decisivecriteria is more whether the profession performing a task is officially recognised as belonging to themedical profession rather than whether the services rendered are medical care in the sense ofexclusively or predominantly aiming at enhancing the health of patients. For the time being, thequantities of resources involved may be negligible. In the future, more specific guidelines may benecessary based on societies’ decisions on this issue.

The borderline between public health and other government functions

9. A wide range of government functions outside of medical care deal with public safety and theprotection of population health. For Health Accounting, the organisation and performance of theseservices has to be separated from the medical care function. The following is a list of possibleboundary cases.

10. Ambulance and rescue services of a general nature but organised by fire-protection services belongto medical care. Base hospitals belong to the medical care function, not the military and civildefence. Medical facilities reserved for war- or peace-time disaster, on the other hand, belong topublic safety or the military and defence function.

11. A range of non-public health type safety measures (road and vehicle safety, construction andhousing standards, veterinarian services and product safety monitoring) are in some countriesadministered by public health authorities.

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ANNEX 2. CROSS-CLASSIFYING THE FUNCTIONAL CLASSIFICATION WITH OTHERINTERNATIONAL CLASSIFICATIONS

Cross-classification with COFOG and COICOP

1. The boundaries proposed for functions HC.1 to HC.6 correspond closely to COICOP function 06and COFOG function 07 in the latest revision of the Classification of Individual Consumption byPurposes and the Classification of Functions of Government (after incorporation of amendments bythe OECD Secretariat). The following cross-classification table also includes the followingdifferences between the ICHA-HC and COFOG/COICOP explicit:

− Private health insurance is classified under health in ICHA; - under a separate insurancecategory in COICOP;

− Family planning services are classified under health in ICHA, - under Family and children inCOFOG;

− Health R&D is a health-related function in ICHA and a genuine health function in COFOG.

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Table 4. Cross-classification of ICHA-HC, COFOG and COICOP

Functions of medical care COFOG COICOP


HC.1.1 In-patient curative care p 07.3 p 06.30HC.1.2 Day cases of curative care p 07.3 p 06.30HC.1.3 Out-patient curative care p 07.2 p 06.2

HC.1.3.1 Basic medical and diagnostic services p 07.2.1 p 06.2.1HC.1.3.2 Medical mental health and substance

abuse therapyp 07.2.2 p 06.2.1

HC.1.3.3 Ambulatory surgical procedures p 07.2.2 p 06.2.1HC.1.3.4 Out-patient dental care p 07.2.3 p 06.2.2HC.1.3.5 All other specialised medical services p 07.2.2 p 06.2.1HC.1.3.9 All other out-patient curative care p 07.2.3 p 06.2.2

HC.1.4 Services of curative home care p 07.2 p 06.1.2

HC.2 Services of rehabilitative care p 07.2.407.2.1

p 06.2.306.2.1

HC.2.1 In-patient rehabilitative care p 07.3 p 06.30HC.2.2 Day cases of rehabilitative care p 07.3 p 06.30HC.2.3 Out-patient rehabilitative care p 07.2.4

07.2.1p 06.2.3

HC.2.4 Services of rehabilitative home care p 07.2.4 p 06.2.3


HC.3.1 In-patient long-term nursing care p 07.1.2 06.1.1

HC.3.1.1 In-patient long-term nursing care fordependent elderly patients

HC.3.1.2 In-patient long-term nursing care formental health and substance abusepatients

HC.3.1.3 All other in-patient long-term nursing careHC.3.2 Day cases of long-term nursing care p 07.1.3 p 06.1.3

HC.3.2.1 Day cases of long-term nursing care fordependent elderly patients

HC.3.2.2 All other day cases of long-term nursingcare

HC.3.3 Long-term nursing care: home care p 07.1.3 p 06.1.2

HC.3.3.1 Long-term nursing care: home care fordependent elderly patients

HC.3.3.2 Long-term nursing care: all other homecare

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Table 5 (cont.) Cross-classification of ICHA-HC, COFOG and COICOP


HC.4.1 Clinical laboratory p 07.2.4 p 06.2.3HC.4.2 Diagnostic imaging p 07.2.4 p 06.2.3HC.4.3 Patient transport and emergency rescue p 07.2.4 p 06.2.3HC.4.9 All other miscellaneous ancillary services p 07.2.4 p 06.2.3


HC.5.1 PharmaceuticalsHC.5.1.1 Prescribed medicines p 07.1.2 06.1.1HC.5.1.2 Over-the-counter medicines p 07.1.2 ---

HC.5.2 Therapeutic appliances and medicalequipment

p 07.1.3 p 06.1.3

HC.5.2.1 Glasses and other vision products p 07.1.3 p 06.1.3HC.5.2.2 Orthopaedic appliances and other

prostheticsp 07.1.3 p 06.1.3

HC.5.2.3 Hearing aids p 07.1.3 p 06.1.3HC.5.2.4 Medico-technical devices, including

wheelchairsp 07.1.3 p 06.1.3

HC.5.2.9 All other miscellaneous medical goods p 07.1.3 p 06.1.2

HC.6 Prevention and public health services ---

HC.6.1 Maternal and child health; family planning andcounselling

HC.6.2 School health services p 07.4.0HC.6.3 Prevention of communicable disease p 07.4.0HC.6.4 Prevention of non-commuicable disease p 07.4.0HC.6.4 Occupational health care ---HC.6.9 All other miscellaneous collective health services p 07.6.0,

07.4.0

HC.7 Health programme administration andhealth insurance

HC.7.1 Health programme administration and healthinsurance: public

p 07.6.0

HC.7.2 Health programme administration and healthinsurance: privateHC.7.2.1 Health programme administration and

health insurance: social insuranceHC.7.2.2 Health programme administration and

health insurance: all other private12.5.3

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ANNEX 3.CROSS-CLASSIFICATION OF WHO “ESSENTIAL PUBLIC HEALTH FUNCTIONS”(EPHFS) WITH THE PUBLIC HEALTH FUNCTIONS IN THE ICHA-HC AND COFOG

Table 5. Cross-classification of EPHFs, ICHA-HC, and COFOG

EPHF Description ICHA-HC COFOG code

1 Prevention, surveillance and control ofcommunicable and non-communicablediseases

Immunisation p 5.3.1 p 07.4Disease outbreak control p 5.3.1 p 07.4Disease surveillance cross-funct.

(5. and 6.)cross-funct.(07.4 and 07.6)

Prevention of injury p 5.3.3 (andcross-funct.)

p 07.4 (and cross-funct.)

2 Monitoring the health situation

Monitoring of morbidity and mortality cross-funct.(5. and 6.)

cross-funct.(07.4 and 07.6)

Evaluation of the effectiveness of promotion,prevention and services programmes

cross-funct.(5. and 6.)

cross-funct.(0.7.4 and 0.7.6)

Assessment of the effectiveness of publichealth functions

p 5. and 6. p 0.7.4 and 0.7.6

Assessment of population needs and risks todetermine which subgroups require service

cross-funct.(5. and 6.)


3 Health promotion

Promotion of community involvement inhealth

p 5.3.9 and 6. p 0.7.4 and 0.7.6

Provision of information and education forhealth and life skill enhancement in school,home, work and community settings

cross-functional(5. and 6.)


Maintenance of linkages with politicians, othersectors and the community in support of healthpromotion and public health advocacy

strategicaspect

strategic aspect

4 Occupational Health (5.4) ---

Setting occupational health and safetystandards

p 6. 07.6.0

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Table 6 (cont.) Cross-classification of EPHFs, ICHA-HC, and COFOG

EPHF Description ICHA-HC COFOG code

5 Protecting the environment

Production and protection of, and access to,safe water

(R.4) p 06.3.0

Control of food quality and safety p R.4 cross-funct. (04;07.04.0)

Provision of adequate drainage, sewerage andsolid waste disposal services

p R.4 p 05.1 and 05.2

Control of hazardous substances and wastes --- p 05.1 and 05.2Provision of adequate vector control measures p 5.3.1 p 07.04.0Ensure protection of water and soil resources (R.5) (05.3; 05.4 and

05.6)Ensure environmental health aspects areaddressed in development policies, plans,programmes and projects

strategicaspect

strategic aspect

Prevention and control of atmosphericpollution

(R.5) p 05.3

Ensure adequate prevention and promoteenvironmental services

strategicaspect

strategic aspect

Ensure adequate inspection, monitoring andcontrol of environmental hazards

strategicaspect

strategic aspect

Controlling radiation p R.5 p 05.3

6 Public health legislation and regulations

Review, formulate and enact healthlegislation, regulations and administrativeprocedures

p 6. p 07.6.0

Ensure adequate legislation to protectenvironmental health

cross-funct.(1. - 4.)

cross-funct.

Health inspection and licensing p 6. p 07.6.0Enforcement of health legislation, regulationsand administrative procedures

cross-sectoral

cross-sectoral

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Table 6 (cont.) Cross-classification of EPHFs, ICHA-HC, and COFOG

EPHF Description ICHA-HCcode

COFOG code

7 Public health management

Ensuring health policy, planning andmanagement

p 6.1.1 (andcross-sectoral)

p 07.6.0 (andcross-sectoral)

Use of scientific evidence in the formulationand implementation of public health policy

strategicaspect

strategic aspect

Public health and health systems research p R.3 p 07.4.0International collaboration and co-operation inhealth

p 6.1 (andcross-sectoral)

p 01.2 (and cross-sectoral)

8 Specific public health services

School health services 5.2 p 07.4.0

Emergency disaster services --- p 03.2.0 and03.6.0

Public health laboratory services p 5.3.1 p 07.4.0

9 Personal health care for vulnerable and highrisk populations

cross-funct.issue

cross-funct.issue

Maternal health care and family planning p 5.1 p 07.4.0 and10.4.0

Infant and child care p 5.1.1 p 07.4.0

p: part of; cross-funct.: cross-functional issue; (R.x): WHO function overlaps with R.x (although notidentical);

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CHAPTER 9. CLASSIFICATION OF MEDICAL CARE INDUSTRIES

1. The ICHA-HI provider-component classifying medical care industries is a refined and modifiedversion of the health relevant parts of ISIC, Rev. 3 (United Nations, 1990). The majority of medicalcare industries in that classification is contained in Section N, Health and Social Work. Healthinsurance, administration and social security schemes are classified under the insurance industry orcorresponding classes of public administration and compulsory social security.

2. The contents of individual categories of medical services under Health and Social Work is definedin ISIC under three broad terms of activities: Hospital activities (ISIC 8511), Medical and dentalpractice activities (ISIC 8512), and Other human health activities (ISIC 8519). Explanatory notesand further health-relevant industries in ISIC are listed in Annex 6 with their original explanatorytext. It is recommended that a well defined link be established between the institutional dimensionof the System of Health Accounts (SHA) and national industrial statistics.

3. For health accounting, more detailed explanations and a substantially longer list of medical careindustries are necessary. For the refinements of ISIC appropriate for the ICHA-HI component, thedraft common industrial classification of NAFTA countries, the NAICS 1998 served as a model forboth basic definitions and for the presentation of specific items. The terminology is modified insome instances to include additional material so as to better take into account the situation in otherOECD countries or to abbreviate and simplify NAICS definitions.

4. Health accountants at national and cross-national level should establish an exchange of informationwith the macro-economic accountants in their countries to ensure that medical care providers areallocated in the same way in both systems. This concerns, e.g. the classification of hospitals aspublic or private corporations. The co-ordination of classifications is particularly importantregarding medical care insurance, for which the SHA adopts the SNA 93 principles of breakingdown insurance schemes into social security, social insurance and other insurance.

5. In its present version, the institutional classification has been designed to allow cross-classificationof expenditure on health reported under the medical functions (HA.1 - HA.7). For health-relatedfunctions (such as education and R&D) specific institutional classifications have been designed andrecommended for international comparisons. These have not been reproduced here (seeUNESCO/OECD/Eurostat, 1995, and the Frascati Manual, OECD, 1994d) although this manualrecommends to closely follow them.

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Table 6. ICHA-Classification of medical care industries

ICHA-HICode

Description

HI.1 Hospitals

HI.1.1 General hospitalsHI.1.2 Mental health and substance abuse hospitalsHI.1.3 Speciality (other than mental health and substance abuse) hospitals

HI.2 Nursing and residential care facilities

HI.2.1 Nursing care facilitiesHI.2.2 Residential mental retardation, mental health and substance abuse facilitiesHI.2.3 Community care facilities for the elderlyHI.2.9 All other residential care facilities

HI.3 Ambulatory health care

HI.3.1 Offices of physiciansHI.3.2 Offices of dentistsHI.3.3 Offices of paramedical practitionersHI.3.4 Out-patient care centres

HI.3.4.1 Family planning centresHI.3.4.2 Out-patient mental health and substance abuse centresHI.3.4.3 Free-standing ambulatory surgery centresHI.3.4.4 Dialysis care centresHI.3.4.9 All other out-patient community and other integrated care

centresHI.3.5 Medical and diagnostic laboratoriesHI.3.6 Home health care servicesHI.3.9 All other ambulatory health care

HI.3.9.1 Ambulance servicesHI.3.9.2 Blood and organ banksHI.3.9.9 All other ambulatory health care services

HI.4 Retail sale and other providers of medical goods

HI.4.1 Dispensing chemistsHI.4.2 Retail sale and other suppliers of optical glasses and other vision productsHI.4.3 Retail sale and other suppliers of hearing aidsHI.4.4 Retail sale and other suppliers of medical appliances (other than optical

glasses and hearing aids)HI.4.9 All other miscellaneous sale and other suppliers of pharmaceuticals and

medical goods

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Table 7. (continued) ICHA-Classification of medical care industries

ICHA-HICode

Description

HI.5 Provision and administration of public health programmes

HI.6 Health administration and insurance

HI.6.1 Government administration of healthHI.6.2 Social security fundsHI.6.3 Other social insuranceHI.6.4 Other (private) insuranceHI.6.9 All other health administration

HI.9 All other industries (rest of the economy)

Explanatory notes

HI.1 Hospitals

6. This item comprises licensed establishments primarily engaged in providing medical, diagnostic,and treatment services that include physician, nursing, and other health services to in-patients andthe specialised accommodation services required by in-patients. Hospitals may also provide out-patient services as a secondary activity. Hospitals provide in-patient health services, many of whichcan only be provided using the specialised facilities and equipment that form a significant andintegral part of the production process. In some countries, health facilities need in addition aminimum size (number of beds) in order to be registered as a hospital.

HI.1.1 General hospitals

7. This item comprises licensed establishments primarily engaged in providing diagnostic and medicaltreatment (both surgical and non-surgical) to in-patients with a wide variety of medical conditions.These establishments may provide other services, such as out-patient services, anatomicalpathology services, diagnostic X-ray services, clinical laboratory services, operating room servicesfor a variety of procedures, and pharmacy services.

Illustrative examples

General acute care hospitals;

Community, County, and Regional hospitals (other than speciality hospitals);

Hospitals of private non-profit-organisations (e.g. Red Cross) (other than speciality hospitals);

Teaching hospitals; University hospitals (other than speciality hospitals);

Army, veterans, and police hospitals (other than speciality hospitals);

Prison hospitals.

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Note

8. Included are integrated community care centres providing both in-patient and out-patient servicesbut which are primarily engaged in in-patient services.

HI.1.2 Mental health and substance abuse hospitals

9. This item comprises licensed establishments that are primarily engaged in providing diagnostic andmedical treatment, and monitoring services to in-patients who suffer from mental illness orsubstance abuse disorders. The treatment often requires an extended stay in an in-patient settingincluding hostelling and nutritional facilities. Psychiatric, psychological, and social work servicesnotably are available at the facility. These hospitals usually provide other services, such as out-patient care, clinical laboratory tests, diagnostic X-rays, and electroencephalography services.

Cross-references

− Establishments primarily engaged in providing treatment of mental health and substance abuseillnesses on an out-patient basis are classified under HI.3.4.2, Out-patient mental health andsubstance abuse centres;

− Establishments referred to as hospitals that are primarily engaged in providing in-patient treatmentof mental health and substance abuse illness with the emphasis on counselling rather than onmedical treatment are classified under HI.2.2, Residential mental retardation, mental health andsubstance abuse facilities;

− Establishments referred to as hospitals that are primarily engaged in providing residential care forpersons diagnosed with mental retardation are classified under HI.2.2, Residential mentalretardation, mental health and substance abuse facilities.

HI.1.3 Speciality (other than mental health and substance abuse) hospitals

10. This item comprises licensed establishments primarily engaged in providing diagnostic and medicaltreatment to in-patients with a specific type of disease or medical condition (other than mentalhealth or substance abuse). Hospitals providing long-term care for the chronically ill and hospitalsproviding rehabilitation, restorative, and adjustive services to physically challenged or disabledpeople are included in this item. These hospitals may provide other services, such as out-patientservices, diagnostic X-ray services, clinical laboratory services, operating room services, physicaltherapy services, educational and vocational services, and psychological and social work services.


Specialised acute hospitals;

Specialised emergency centres;

Orthopaedic hospitals;

Speciality sanitoriums (primarily engaged in medical post-acute, rehabilitative and preventiveservices);

Special hospitals for infectious disease (Tuberculosis hospitals; Hospitals for tropical diseases).

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Cross-references

− Establishments licensed as hospitals primarily engaged in providing diagnostic and therapeutic in-patient services for a variety of medical conditions, both surgical and non-surgical, are classifiedunder HI.1.1, General hospitals;

− Establishments known and licensed as hospitals primarily engaged in providing diagnostic andtreatment services for in-patients with psychiatric or substance abuse illnesses are classified underHI.1.2, Mental health and substance abuse hospitals;

− Establishments referred to as hospitals but primarily engaged in providing in-patient nursing andrehabilitative services to persons requiring convalescence are classified under HI.2.1, Nursing carefacilities;

− Establishments referred to as hospitals but primarily engaged in providing residential care ofpersons diagnosed with mental retardation are classified under HI.2.2, Residential mentalretardation, mental health and substance abuse facilities;

− Establishments referred to as hospitals but primarily engaged in providing in-patient treatment formental health and substance abuse illnesses with the emphasis on counselling rather than medicaltreatment are classified under HI.2.2, Residential mental retardation, mental health and substanceabuse facilities.


11. This item comprises establishments primarily engaged in providing residential care combined witheither nursing, supervisory or other types of care as required by the residents. In theseestablishments, a significant part of the production process and the care provided is a mix of healthand social services with the health services being largely at the level of nursing services.

Note

12. A wide range of institutions providing long-term care exists in most countries. The medicalcomponent is the predominant component or in cost terms an important one. The exactclassification in the corresponding types of institutions (Nursing care facilities, Residential mentalretardation, mental health and substance abuse facilities, Community care facilities for the elderly,Other residential care facilities) depends on the country-specific division of labour in the careprocess, especially in long-term care. As a general rule, in health accounting all institutions shouldbe reported, where a considerable share of all activities performed in that institution have a medicalcomponent or consist of nursing care with a strong medical component, usually performed bymedical personnel acting as employees of the institution.

Cross-references

13. Institutions where medical interventions are more of an incidental character or are performed byvisiting doctors and/or nurses are excluded. This should also apply to institutions with a physicianacting as director of e.g., a home for handicapped persons, where medical and nursing care accounts

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for only a small share of the overall activity of that institution. Another example of institutions ofthis type is residential homes for the elderly with visiting nurses. Nurses visiting these institutionsshould be reported separately as a corresponding category of ambulatory care (HI.3).

HI.2.1 Nursing care facilities

14. This item comprises establishments primarily engaged in providing in-patient nursing andrehabilitative services. The care is generally provided for an extended period of time to individualsrequiring nursing care. These establishments have a permanent core staff of registered or licensedpractical nurses who, along with other staff, provide nursing and continuous personal care services.

Note

15. Medical nursing care facilities provide predominantly long-term care but also occasionally acutemedical care and nursing care in conjunction with accommodation and other types of support suchas assistance with day-to-day living tasks and assistance towards independent living. Nursinghomes provide long-term care involving regular basic nursing care to chronically ill, frail, disabledor convalescent persons or senile persons placed in an in-patient institution. Medical care andtreatment have to constitute an important part of the activities provided. Hostels with only limitedmedical assistance, such as supervision of compliance with medication, should be excluded.


Convalescent homes or convalescent hospitals (other than Mental health and substance abusefacilities);

Homes for the elderly with nursing care;

In-patient care hospices;

Nursing homes;

Rest homes with nursing care;

Skilled nursing facilities (USA);

Teaching nursing homes.

Cross-references

− Assisted-living facilities with on-site nursing care facilities are classified under HI.2.3, Communitycare facilities for the elderly,

− Mental health convalescent homes are classified under HI.2.2, Residential mental retardation,mental health and substance abuse facilities.

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HI.2.2 Residential mental retardation, mental health and substance abuse facilities

16. This item comprises establishments (e.g. group homes, hospitals, intermediate care facilities)primarily engaged in providing in an in-patient setting domiciliary services for persons diagnosedwith mental retardation. These facilities may provide some health care, though the focus is on roomand board, protective supervision, and counselling. Residential mental health and substance abusefacilities comprise establishments primarily engaged in providing residential care and treatment forpatients with mental health and substance abuse illnesses. These establishments provide room,board, supervision, and counselling services. Although medical services may be available at theseestablishments, they are incidental to the counselling, mental rehabilitation, and support servicesoffered. These establishments generally provide a wide range of social services in addition tocounselling.


Alcoholism or drug addiction rehabilitation facilities (other than licensed hospitals);

Mental health halfway houses (USA);

Mental health convalescent homes or hospitals;

Residential group homes for the emotionally disturbed;

MENCARE (Sweden).

Cross-references

− Establishments primarily engaged in providing treatment of mental health and substance abuseillnesses on a predominantly out-patient basis are classified under HI.3.4.2, Out-patient mentalhealth and substance abuse centres;

− Establishments known and licensed as hospitals primarily engaged in providing in-patient treatmentof mental health and substance abuse illnesses with an emphasis on medical treatment andmonitoring are classified under HI.1.2, Mental health and substance abuse hospitals.

HI.2.3 Community care facilities for the elderly

17. This item comprises establishments primarily engaged in providing residential and personal careservices for elderly and other persons (1) unable to fully care for themselves and/or (2) unwilling tolive independently. The care typically includes room, board, supervision, and assistance in dailyliving, such as housekeeping services. In some instances these establishments provide skillednursing care for residents in separate on-site facilities. Assisted living facilities with on-site nursingcare facilities are included in this item. Homes for the elderly without on-site nursing care facilitiesare also included.

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Assisted-living facilities;

Continuing care retirement communities;

Homes for the elderly without nursing care.

HI.2.9 All other residential care facilities

18. This item comprises establishments primarily engaged in providing residential care (other thanresidential mental retardation, mental health, and substance abuse facilities and Community carefacilities for the elderly) often together with supervision and personal care services.


Group homes for the hearing or visually impaired;

Group homes for the disabled without nursing care.

Cross-references

− Residential mental retardation facilities are classified under HI.2.2, Residential mental retardation,mental health and substance abuse facilities;

− Continuing care retirement communities and homes for the elderly without nursing are classifiedunder HI.2.3, Community care facilities for the elderly;

− Establishments primarily engaged in providing in-patient nursing and rehabilitative services areclassified under HI.2.1, Nursing care facilities.


19. This item comprises establishments primarily engaged in providing health care services directly toout-patients who do not require in-patient services. Consequently, these establishments do notusually provide in-patient services. Health practitioners in ambulatory health care primarilyprovide services to patients visiting the health professional’s office except for some paediatric andgeriatric conditions. The facilities and equipment are usually not the most significant part of theproduction process.

HI.3.1 Offices of physicians

20. This item comprises establishments of health practitioners holding the degree of a doctor ofmedicine or a qualification at a corresponding level (ISCO 88 fourth degree level) primarilyengaged in the independent practice of general or specialised medicine (including psychiatry,psychoanalysis, osteopathy, homeopathy) or surgery. These practitioners operate private or group

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practices in their own offices (e.g., centres, clinics) or in the facilities of others, such as hospitals orHMO type medical centres.


General practitioners in private offices;

Specialists of a wide range of specialities in private offices;

Establishments known as medical clinics which are primarily engaged in the treatment of out-patients (Korea, Japan).

Cross-references

− Free-standing medical centres primarily engaged in providing emergency medical care for accidentor catastrophe victims and free-standing ambulatory surgical centres are classified under HI.3.4,Out-patient care centres.

HI.3.2 Offices of dentists

21. This item comprises establishments of health practitioners holding the degree of Doctor of dentalmedicine or a qualification at a corresponding level (ISCO 88 fourth degree level) primarilyengaged in the independent practice of general or specialised dentistry or dental surgery. Thesepractitioners operate private or group practices in their own offices (e.g., centres, clinics) or in thefacilities of others, such as hospitals or HMO medical centres. They can provide eithercomprehensive preventive, cosmetic, or emergency care, or specialise in a single field of dentistry.

Cross-references

− Dental laboratories primarily engaged in making dentures, artificial teeth, and orthodonticappliances to order for dentists are classified under HI.5.4, Retail sale and manufacturing of medicalappliances (other than optical glasses and hearing aids);

− Establishments of dental hygienists primarily engaged in cleaning teeth and gums or establishmentsof denturists primarily engaged in taking impressions for and fitting dentures are classified underHI.3.3, Offices of paramedical practitioners.

HI.3.3 Offices of paramedical practitioners

22. This item comprises establishments of independent health practitioners (other than physicians, anddentists), such as chiropractors, optometrists, mental health specialists, physical, occupational, andspeech therapists and audiologists establishments primarily engaged in providing care to out-patients. These practitioners operate private or group practices in their own offices (e.g., centres,clinics) or in the facilities of others, such as hospitals or HMO medical centres.

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Note

23. This item includes paramedical practitioners providing so-called "traditional medicine" without adoctor’s approbation. Some form of legal registration and licensing (implying a minimum of publiccontrol over the contents of care provided) should be regarded as a necessary condition in order tobe reported as paramedical practitioner.


Nurses;

Acupuncturists’ offices (other than physicians);

Chiropractors;

Physiotherapists and physical therapists;

Occupational and Speech Therapists;

Audiologists;

Dental hygienists’ offices;

Denturists’ offices;

Dieticians’ offices;

Homeopaths’ offices (other than physicians);

Inhalation or respiratory therapists’ offices;

Midwives’ offices;

Naturopaths’ offices (other than physicians);

Podiatrists’ offices;

Registered or licensed practical nurses’ offices.

Cross-references

− The independent practice of medicine and mental health by physicians is classified under HI.3.1,Offices of physicians;

− The independent practice of dentistry is classified under HI.3.2, Offices of dentists;

− The independent practice of home health care services is classified under HI.3.6, Home health careservices.

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HI.3.4 Out-patient care centres

24. This item comprises establishments with medical staff primarily engaged in providing a wide rangeof out-patient services provided by a team of medical, paramedical and often also support staff,usually bringing together several specialities and/or serving specific functions of primary care.These establishments generally treat patients who do not require in-patient treatment.

HI.3.4.1 Family planning centres

25. This item comprises establishments with medical staff primarily engaged in providing a range offamily planning services on an out-patient basis, such as contraceptive services, genetic andprenatal counselling, voluntary sterilisation, and therapeutic and medically indicated termination ofpregnancy.


Pregnancy counselling centres;

Birth control clinics;

Childbirth preparation classes;

Fertility clinics.

HI.3.4.2 Out-patient mental health and substance abuse centres

26. This item comprises establishments with medical staff primarily engaged in providing out-patientservices related to the diagnosis and treatment of mental health disorders and alcohol and othersubstance abuse. These establishments generally treat patients who do not require in-patienttreatment. They may provide a counselling staff and information regarding a wide range of mentalhealth and substance abuse issues and/or refer patients to more extensive treatment programmes, ifnecessary.


Out-patient alcoholism treatment centres and clinics (other than hospitals);

Out-patient detoxification centre and clinics (other than hospitals);

Out-patient drug addiction treatment centres and clinics (other than hospitals);

Out-patient mental health centres and clinics (other than hospitals);

Out-patient substance abuse treatment centres and clinics (other than hospitals).

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Cross-references

− Hospitals primarily engaged in the in-patient treatment of mental health and substance abuseillnesses with an emphasis on medical treatment and monitoring are classified under HI.1.2, Mentalhealth and substance abuse hospitals;

− Establishments primarily engaged in the in-patient treatment of mental health and substance abuseillness with an emphasis on residential care and counselling rather than medical treatment areclassified under HI.2.2 Residential mental health and substance abuse facilities.

HI.3.4.3 Free-standing ambulatory surgery centres

27. This item comprises establishments with physicians and other medical staff primarily engaged inproviding surgical services (e.g., orthoscopic and cataract surgery) on an out-patient basis. Out-patient surgical establishments have specialised facilities, such as operating and recovery rooms,and specialised equipment, such as anaesthetic or X-ray equipment.

Cross-references

− Physician walk-in centres are classified under HI.3.1, Offices of physicians;

− Hospitals that also perform ambulatory surgery and emergency room services are classified underHI.1, Hospitals.

HI.3.4.4 Dialysis care centres

28. This item comprises establishments with medical staff primarily engaged in providing out-patientkidney or renal dialysis services.

HI.3.4.9 All other out-patient community and other integrated care centres

29. This item comprises establishments with medical staff primarily engaged in providing general orspecialised out-patient care (other than family planning centres, out-patient mental health andsubstance abuse centres, free-standing ambulatory surgical centres and kidney dialysis centres andclinics). Centres or clinics of health practitioners with different degrees from more than onespeciality practising within the same establishment (i.e., physician and dentist) are included in thisitem.


Out-patient community centres and clinics;

Free-standing emergency medical centres and clinics;

Out-patient pain therapy centres and clinics.

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Note:

30. Included are health maintenance organisation (HMO) medical centres and clinics. HMO typemedical centres comprise establishments with physicians and other medical staff primarily engagedin providing a range of out-patient medical services to the HMO subscribers with a focus generallyon primary health care. These establishments are owned by the HMO. Included are HMOestablishments that both provide health are services and underwrite health and medical insurancepolicies. Included are integrated community care centres providing both in-patient and out-patientservices primarily engaged in out-patient services.

Cross-references

− Physician walk-in centres are classified under HI.3.1, Offices of physicians;

− Centres and clinics of health practitioners primarily engaged in the independent practice of theirprofession are classified under HI.3.1 Offices of physicians; HI.3.2 Offices of dentists; and HI.3.3,Offices of paramedical practitioners;

− HMO establishments (other than those providing health care services) primarily engaged inunderwriting health and medical insurance policies are classified under HI.6, Health administrationand insurance.

HI.3.5 Medical and diagnostic laboratories

31. This item comprises establishments primarily engaged in providing analytic or diagnostic services,including body fluid analysis and diagnostic imaging, generally to the medical profession or thepatient on referral from a health practitioner.


Diagnostic imaging centres;

Dental or medical X-ray laboratories;

Medical testing laboratories;

Medical pathology laboratories;

Medical forensic laboratories.

Cross-references

32. Establishments, such as dental, optical, and orthopaedic laboratories, primarily engaged inproviding the following activities to the medical profession, respectively: making dentures,artificial teeth, and orthodontic appliances to prescription; making lenses to prescription; andmaking orthopaedic or prosthetic appliances to prescription are classified under HI.5, Retail saleand other providers of medical goods.

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HI.3.6 Home health care services

33. This item comprises establishments primarily engaged in providing skilled nursing services in thehome, along with a range of the following: personal care services; homemaker and companionservices; physical therapy; medical social services; medications; medical equipment and supplies;counselling; 24-hour home care; occupation and vocational therapy; dietary and nutritional services;speech therapy; audiology; and high-tech care, such as intravenous therapy.


Community nurses and domiciliary nursing care (including child day-care in the case of sickness);

Home health care agencies;

In-home hospice care services;

Visiting nurse associations.

HI.3.9 All other ambulatory health care

34. This item comprises a variety of establishments primarily engaged in providing ambulatory healthcare services (other than offices of physicians, dentists, and other health practitioners; out-patientcare centres; medical laboratories and diagnostic imaging centres; and home health care providers).

HI.3.9.1 Ambulance services

35. This item comprises establishments primarily engaged in providing transportation of patients byground or air, along with medical care. These services are often provided during a medicalemergency but are not restricted to emergencies. The vehicles are equipped with lifesavingequipment operated by medically trained personnel.

Note

36. This item includes ambulance services provided in peacetime, non-disaster situations by the army,police or fire brigade.

Cross-references

37. Establishments primarily engaged in providing transportation of the disabled or elderly (withoutproviding medical care, such as taxi drivers) are classified under HI.9 All other industries.

HI.3.9.2 Blood and organ banks

38. This item comprises establishments primarily engaged in collecting, storing and distributing bloodand blood products and storing and distributing body organs.

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Blood donor stations.

HI.3.9.9 All other ambulatory health care services

39. This item comprises establishments primarily engaged in providing ambulatory health care services(other than offices of physicians, dentists, and other health practitioners; out-patient care centres;medical and diagnostic laboratories; home health care providers; ambulances; and blood andorgan banks).


Health screening services (except by offices of health practitioners);

Hearing testing services (except by offices of audiologists);

Pacemaker monitoring services;

Physical fitness evaluation services (except by offices of health practitioners);

Smoking cessation programmes.


40. This item comprises establishments whose primary activity is the retail sale of medical goods to thegeneral public for personal or household consumption or utilisation. Establishments whose primaryactivity is the manufacture of medical goods for sale to the general public for personal or householduse are also included as well as fitting and repair done in combination with sale.

HI.4.1 Dispensing chemists

41. This item comprises establishments primarily engaged in the retail sale of pharmaceuticals to thegeneral public for personal or household consumption or utilisation. Instances when the processingof medicine may be involved should be only incidental to selling. This includes both medicine withand without prescription.


Public pharmacies.

Cross-references

42. Pharmacies in hospitals serving mainly out-patients are part of establishments classified under HI.1,Hospitals.

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43. Specialised dispensaries where the continuous monitoring of compliance and treatment plays animportant role (such as for diabetes patients), are classified under HI.3.4, Out-patient care centres.

HI.4.2 Retail sale of optical glasses and other vision products

43. This item comprises establishments primarily engaged in the retail sale of optical glasses and othervision products to the general public for personal or household consumption or utilisation. Thisincludes the fitting and repair provided in combination with sales of optical glasses and other visionproducts.

Illustrative example

Optical goods stores (optical laboratories grinding lenses with or without prescription).

HI.4.3 Retail sale of hearing aids

44. This item comprises establishments primarily engaged in the sale of hearing aids to the generalpublic for personal or household consumption or utilisation. This includes the fitting and repairprovided in combination with the sale of hearing aids.

HI.4.4 Retail sale of medical appliances (other than optical goods and hearing aids)

45. This item comprises establishments primarily engaged in the sale of medical appliances other thanoptical goods and hearing aids to the general public with or without prescription for personal orhousehold consumption or utilisation. Included are establishments primarily engaged in themanufacture of medical appliances but where the fitting and repair is usually done in combinationwith manufacture of medical appliances, such as dental laboratories.

Illustrative example

Dental laboratories.

HI.4.9 All other miscellaneous sale and other suppliers of pharmaceuticals and medical goods

46. This item comprises establishments engaged in the sale of other miscellaneous retail sale of medicalgoods to the general public for personal or household consumption or utilisation (included are salesnot by shops such as electronic shopping and mail-order houses).


Sale of fluids (e.g. for home dialysis);

All other miscellaneous health and personal care stores;

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All other sale of pharmaceuticals and medical goods;

Electronic shopping and mail-order houses specialised in medical goods.


47. This item comprises both government and private administration and provision of public healthprogrammes such as health promotion and protection programmes.


Government provision and administration of public health programmes (as part of ISIC class 7512);

Public health department/district (USA: local health agency).

HI.6 General health administration and insurance

48. This item comprises establishments primarily engaged in the regulation of activities of agencies thatprovide health care, overall administration of health policy, and health insurance.

Note

49. The role and definition of health insurance and other forms of financing medical care are discussedin more detail in Chapters 6 and 10 together with the description of health insurance regulation.

HI.6.1 Government administration of health

50. This item comprises government administration primarily engaged in the formulation andadministration of government policy in health and in the setting and enforcement of standards formedical and para-medical personnel and for hospitals, clinics, etc., including the regulation andlicensing of providers of health services.


Ministry of Health;

Board of Health;

Food and drug regulation agencies;

Agencies for the regulation of safety on the workplace.

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Cross-references

51. Government health agencies providing public health services even if predominantly of a collectivenature (surveillance, hygiene), are classified under HI.5, Provision and administration of publichealth programmes.

HI.6.2 Administration of compulsory social security programmes

52. This item comprises the funding and administration of government-provided compulsory socialsecurity programmes compensating for reduction of loss of income or inadequate earning capacitydue to sickness (as part of ISIC 7530).


Administration of compulsory social health insurance and sickness funds;

Administration of compulsory employer’s sickness funds;

Administration of compulsory social health insurance covering various groups of state employees(army, veterans, railroad and other public transport, police, state officials etc.).

HI.6.3 Other social insurance

53. This item comprises the funding and administration of social insurance (other than government-provided compulsory social security programmes) compensating for reduction or loss of income orinadequate earning capacity due to sickness.


Administration of private social health insurance and sickness funds;

Administration of complementary social insurance (Mutualité);

Administration of employer’s social health insurance schemes (other than government socialsecurity schemes).

HI.6.4 Other (private) insurance

54. This item comprises insurance of health (as part of ISIC class 6603) other than by social securityfunds and other social insurance. This includes establishments primarily engaged in activitiesinvolved in or closely related to the management of insurance (activities of insurance agents,average and loss adjusters, actuaries, and salvage administration (part of ISIC class 6720)).

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HI.9 All other industries

55. This item comprises all other industries providing medical care or public health services as asecondary activity.


Occupational medical services not provided in separate medical care establishments (all industries);

Military health services not provided in separate medical care establishments;

Prison health services not provided in separate medical care establishments;

School health services.

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ANNEX. CROSS-CLASSIFICATION OF ICHA-HI WITH ISIC, NACE AND NAICS

1. The following table cross-classifies the ICHA-HI with ISIC. Industries at the boundary of medicalcare are represented by the shaded areas.

Table 7. Cross-classification of ICHA-HI with ISIC classes

ICHA-HI Code Description ISIC class

HI.1 Hospitals

HI.1.1 General hospitals 8511HI.1.2 Mental health and substance abuse hospitals 8511HI.1.3 Speciality (other than mental health and substance abuse)

hospitals8511


HI.2.1 Nursing care facilities 8519/8531HI.2.2 Residential mental retardation, mental health and substance

abuse facilities8519/8531

HI.2.3 Community care facilities for the elderly 8519/8531HI.2.9 All other residential care facilities 8519/8531


HI.3.1 Offices of physicians 8512HI.3.2 Offices of dentists 8512HI.3.3 Offices of paramedical practitioners 8519HI.3.4 Out-patient care centres 8519

HI.3.4.1 Family planning centres 8519HI.3.4.2 Out-patient mental health and substance abuse

centres8519

HI.3.4.3 Free-standing ambulatory surgery centres 8519HI.3.4.4 Dialysis care centres 8519HI.3.4.9 All other out-patient community and other integrated

care centres8519/8531

HI.3.5 Medical and diagnostic laboratories 8519HI.3.6 Home health care services 8519/8531HI.3.9 All other ambulatory health care 8519

HI.3.9.1 Ambulance services 8519HI.3.9.2 Blood and organ banks 8519HI.3.9.9 All other ambulatory health care services 8519

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Table 8. (continued) Cross-classification of ICHA-HI with international industrialclassifications

ICHA-HI Code Description ISIC class


HI.4.1 Dispensing chemists 5231HI.4.2 Retail sale and other suppliers of optical glasses and other

vision products5239

HI.4.3 Retail sale and other suppliers of hearing aids 5239HI.4.9 All other miscellaneous sale and other suppliers of

pharmaceuticals and medical goods5231/5239


HI.6 Health administration and insurance

HI.6.1 Government administration of health 7512HI.6.2 Social security funds 7530HI.6.3 Other social insurance -HI.6.4 Other (private) insurance 6603HI.6.9 All other health administration -

HI.9 All other industries (rest of the economy) -

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CHAPTER 10. CLASSIFICATION OF MEDICAL CARE FINANCING

1. The study of medical care financing in health accounts starts with the basic sectoral division of thenational accounts, i.e. government agencies, public and private insurance. The following tableshows the financing component of the proposed ICHA classification. It is recommended that usebe made of SNA 93 guidelines for allocating financing agents to the categories of the ICHA-financing components. Consultation between statisticians responsible for the SHA and theircolleagues of National Accounting should ensure that financing agents are allocated in the sameway in the two reporting systems.

2. 1. When consumption is recorded on an expenditure basis, the purpose is to identify theinstitutional units that incur the expenditures and hence control and finance the amounts of suchexpenditure. According to national accounting rules, the above borderline between public andprivate consumption is aimed at. The first step towards a cross-classification of expenditure onhealth and their "financing" will be to recall some basic definitions of national accounting and howthey apply to total expenditure on health and its components. Basic definitions are given in thetable below.

Territorial government

3. Territorial government is the term used here for general government without social securityschemes. The importance of financing in medical care by state budgets depends on the basicorganisation of a country’s medical care system. Financing out of the state budget constitutes themajor form of medical care financing in highly integrated medical care systems, where governmentbodies on state and regional levels are directly responsible for both financing and producingmedical services. The share of government financing is usually less important in countries with amedical care system of the "social insurance-type", where social security funds act as intermediaryfinancing agents.

4. 2. In every OECD country, governments are at least partly responsible for medical care financing,by caring for specific groups of the population (the elderly, unemployed, pensioners, those living onsocial aid, etc.). Government bodies also play an important role in medical care by subsidisingproviders, and through capital formation finance in, for example, hospitals of which many arepublicly owned.

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Table 8. ICHA-Classification of medical care financing

ICHA-code Description

HF.1 General government financing of medical care

HF.1.1 Territorial government

HF.1.1.1 Central government

HF.1.1.2 State/regional/provincial government

HF.1.1.3 Local/municipal government

HF.1.2 Social security schemes

HF.2 Private sector financing of medical care

HF.2.1 Private social insurance schemes

HF.2.2 Other private insurance

HF.2.3 Private households’ out-of-pocket payment

HF.2.3.1 Cost-sharing: social security

HF.2.3.2 Cost-sharing: private social insurance

HF.2.3.4 Cost-sharing: other private insurance

HF.2.3.9 All other out-of-pocket payment

HF.2.9 All other miscellaneous private financing agents

Social insurance and social security schemes

5. Social health insurance exists in different institutional forms, according to the regulations governingthe individual insurance funds. Moreover, it is not always easy to draw an appropriate boundaryline between social health insurance and privately funded and unfunded health insurance schemes.Guidelines for this distinction are provided by SNA 93, Annex 4.

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Box 5. Social insurance schemes

A social insurance scheme is one where the policy-holder is obliged or encouraged to insureagainst certain contingencies by the intervention of a third party. For example, government mayoblige all employees to participate in a social security scheme; employers may make it a conditionof employment that employees participate in an insurance scheme specified by the employer; anemployer may encourage employees to join a scheme by making contributions on behalf of theemployee; or a trade union may arrange advantageous insurance cover available only to themembers of the trade union. Contributions to social insurance schemes are usually paid on behalfof employees, though under certain conditions non-employed or self-employed persons may also becovered. An insurance scheme is designated as a social insurance scheme in the System:

a) If the benefits received are conditional on participation in the scheme; and

b) At least one of the three conditions following is met:

i. Participation in the scheme is compulsory either by law or by the conditions of employment;or

ii. The scheme is operated on behalf of a group and restricted to group members; or

iii. An employer makes a contribution to the scheme on behalf of an employee

Source: adapted from SNA 93, Annex IV, para. 4.111

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Box 6. Social security schemes

Social security schemes are social insurance schemes covering the community as a whole or largesections of the community that are imposed and controlled by a government unit. They generallyinvolve compulsory contributions by employees or employers or both, and the terms on whichbenefits are paid to recipients are determined by a government unit. ... Social security schemeshave to be distinguished from ... other social insurance schemes which are determined by mutualagreement between individual employers and their employees.

Social security funds may be distinguished by the fact that they are organised separately from theother activities of government units and hold their assets and liabilities separately from the latter.They are separate institutional units because they are autonomous funds, they have their own assetsand liabilities and engage in financial transactions on their own account. However, institutionalarrangements in respect of social security differ from country to country and in some countries theymay become so closely integrated with the other finances of government as to bring into questionwhether they should be treated as a separate sub-sector. The amounts raised, and paid out, in socialsecurity contributions and benefits may be deliberately varied in order to achieve objectives ofgovernment policy that have no direct connection with the concept of social security as a scheme toprovide social benefits to members of the community. They may be raised or lowered in order toinfluence the level of aggregate demand in the economy. Nevertheless, so long as they remainseparately constituted funds they must be treated as separate institutional units in the System.

Source: SNA 93, Annex IV, para. 4.112

6. The various forms of out-of-pocket payments and cost-sharing by private households are listed inthe following box.

Box 7. Out-of-pocket payments and cost-sharing by private households.

Out-of-pocket payments: Payments borne directly by a patient without the benefit of insurance.They include cost-sharing and informal payments to medical care providers.

Cost-sharing: a provision of health insurance or third-party payment that requires the individualwho is covered to pay part of the cost of medical care received. This is distinct from the payment ofa health insurance premium, contribution or tax which is paid whether medical care is received ornot. Cost-sharing can be in the form of deductibles, co-insurance or co-payments.

Co-payment: cost-sharing in the form of a fixed amount to be paid for a service.

Co-insurance: cost-sharing in the form of a set proportion of the cost of a service. In France andBelgium, "ticket modérateur".

Deductibles: cost sharing in the form of a fixed amount which must be paid for a service beforeany payment of benefits can take place.

Source: adapted from the glossary in OECD (1992, p. 9)

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7. Private funding is at the moment the least reliable component of medical care financing (mainly dueto uncertainties with respect to the amount of out-of-pocket payments to medical care providers andpharmacies) and also one of the major sources of estimation error in total expenditure on health inmany countries. Data sources for a detailed breakdown of out-of-pocket financing by privatehouseholds are consequently one of the weak points on existing health accounts in many countries.For this reason, more specific household surveys for tracking private expenditure on a regular basisare recommended.

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