A C T A U N I V E R S I T A T I S L O D Z I E N S I S
FOLIA OECONOMICA 182, 2004
J a d w ig a S u c h e c k a *, A g n ie s z k a S tr z e le c k a **
OUTLAYS ON HEALTH PROTECTION IN POLANI)
AND IN THE EUROPEAN UNION - A SPACE-TIME ANALYSIS
1. In trod u ction
Health care is one o f the biggest and most dynam ic - as far as new jo bs form ation and innovation is concerned - sectors o f the national econom y. This is a sector w hich is getting more and more com plex to finance, and for which financial analyses should be carried out in such a way as to guarantee their reliability and contribute favourably to P oland’s preparations for entering the EU structures.
One o f the strategic aims o f the EU for the years 2 0 0 0 -2 0 0 6 regarding public health can be defined as follows: “the m em ber countries should endeavour to unify their own stock o f inform ation in order to enable com parative analyses” .
At present, due to the existent differences across individual countries respecting health sector and other social or econom ic fields o f activity, various m ethods o f classification, diversity in inform ation presented and in standing rules, it is very troublesom e to perform reliable international com parisons. N ational system s o f financing health care tend tow ards creation o f com m on - for all countries - m eans o f classification o f outlays on health care so as to enable sound com parative analyses based on such inform ation. N ational H ealth A ccounts (N H A ) are best suited to do so. N H A are a set o f health care stock that make it possible for countries o f different system s o f financing health care to look into the health care sector, first o f all, from the view point o f international com parisons.
For the sake o f international com parison the total outlays on health protection are grouped according to the classification proposed by the OECD.
* Prof., U niversity o f Łódź.
W hile running international com parisons o f total outlays on health protection, it is o f crucial im portance to count the outlays per capita and convert the calculations into the world currency (e.g. the USA dollar) allow ing for the purchasing pow er o f a local currency or, alternatively, express the outlays as a fraction o f GDP. T he level o f outlays on health protection is strongly related to the G D P level per capita. D ifferences in purchasing pow er parity between individual coun tries’ currencies require converting nominal outlays in line with the official exchange rates into the so-called real per capita outlays. T o this end the face value o f outlays is contrasted with its purchasing pow er parity (PPP).
Estim ation o f outlays on health protection in a given country follow ed by a com parison with other countries' expenditures often forms a ground on the basis o f which conclusions are drawn with respect to the effectiveness and m anagem ent o f the health care system existent in such a country. H ow ever, such a com parison com es across a lot o f difficulties both in the process o f the analysis itself as well as while interpreting results. Some o f such difficulties result from the specificity o f the health sector, first o f all, from m ethods o f m easurem ent, data collection and interpretation o f the obtained results. M oreover, various systems o f m anagem ent and financing o f health protection, existent across different countries, exhibit diversity in the structure and volum e o f m eans engaged, and consequently, in absorption o f the m eans by the sector in individual groups o f system s as well as in particular countries under a given health care system.
The basic purpose o f our paper is to present the outlays on health protection in Poland within the years 1990-2000, contrasted with the EU average. Some prelim inary results based on a space-tim e analysis are also reported in the paper.
2. O u tlay s on h ealth p rotection - a co m p arative a n a lysis
A dequate m anagem ent o f health protection funds calls for m ultifarious analyses o f the health care system, including international com parisons. Still, even in the EU m em ber countries such analyses run into a lot o f difficulties. It is easier to perform an investigation for each country separately than to run a joint inter-country analysis. T hose difficulties stem from different national health accounts across various countries, and what is m ore, the accounts, being at varied stages o f developm ent and circum stantialities, m ake use o f diverse classification systems. By reason o f the intensifying integration processes taking place in Europe, the O EC D put forward System o f H ealth A ccounts (SHA) which provides a com m on layout o f the inform ation tables on outlays on health and m eans o f financing the outlays. The introduction o f the SHA by the end of
2002 in all the EU m em ber countries was forced by E U R O STA T. This was meant to be one o f the elem ents im plem enting the program m e o f the EU in the field o f public health.
The follow ing countries belong to the group that started im plem enting the pilot project: D enm ark, Finland, Germ any, Ireland, Luxem burg, H olland, Spain, and G reat B ritain (see: T able 1). For over a year the above-m entioned countries have been w orking on assessing the introduction o f the tables o f the International C lassification o f Health A ccounts (ICHA).
Table 1. O verview o f the situation regarding introduction o f the pilot SH A in the EU member countries (2001)
Country
Present state o f introduction o f the SHA
Availability o f a project design o f the SH A standard tables project team work in progress available tables providers x function financing x providers financing x function Austria X ( - ) ( - ) ( - ) ( - ) ( - ) B elgium X ( - ) ( - ) ( - ) ( - ) ( - ) Denmark X X X X x X Finland X ( - ) ( - ) X X X France ( - ) (X ) ( - ) ( - ) ( - ) ( - ) Germany X X X X X X Greece (x) ( - ) _ ( - ) ( - ) ( - ) ( - ) Ireland X X ( - ) X X X Italy X ( - ) ( - ) ( - ) ( - ) ( - ) Luxemburg X X X X X X Holland X X X X X X Portugal X (X ) ( - ) ( - ) ( - ) ( - ) Spain X X X X X X Sweden X X ( - ) ( - ) X X Great Britain X X ( - ) ( - ) X X
x - yes, (x) - unconfirmed, ( - ) non available or unknown situation
S o u r c e : K ońcow y Raport Techniczny. Opracowanie i w drożenie N arodow ego Rachunku Zdrowia. Projekt IBRD, Warszawa 2002.
T he level o f outlays on health protection is strongly dependent on the level o f G ross D om estic Product (G D P) per capita. G D P reflects econom ic potential o f a given country as well as her welfare. It also inform s us about the level of resources that can be spent on public and private consum ption or on investm ent within a given year. T he share o f outlays on health protection (both total and public) in G D P is considerably low er in Poland than the EU average (see: Tab. 2 and Fig. 1). G erm any is the country from am ong all the E U m em bers, w hose share is the highest. Poland contrasted with other countries takes the last but one position; she outstrips only Luxem burg. H ow ever, w hile conducting any kind of
research, one should take into account the econom ic standing o f the countries under investigation, especially the living standards o f the societies.
Table 2. Share o f G DP spent on health protection in the EU countries 11 the years 1 9 9 0 -2 0 0 0
Outlays on health in % o f GDP Countries Years •90 •91 •92 ‘93 •94 ‘95 ‘96 ‘97 ‘98 ‘99 •oo Total EU mean 7.5 7.7 8.0 8.1 8.0 8.1 8.2 8.0 7.9 8.1 8.0 Poland 5.3 6.6 6.6 6.4 6.0 6.0 6.4 6.1 6.4 6.2 6.3 Public EU mean 5.8 6.0 6.1 6.2 6.0 6.0 6.1 5.9 5.9 6.0 6.0 Poland 4.8 5.0 5.1 4.7 4.3 4 .4 4.7 4.4 4.2 4.6 4.3 Private EU mean 1.8 1.8 1.9 2.0 2.0 2.0 2.1 2.1 2.0 2.1 2.1 Poland 0.4 1.6 1.6 1.7 1.6 1.6 1.7 1.7 1.8 1.7 2.0
S o u r c e : Own calculations based on OECD Health o f Data 2002.
9
8
3? 7
6
5
F ig . 1. S h a re o f total o u tla y s in G D P o n h ealth p ro te ctio n in th e E U c o u n tr ie s and in P o la n d in the years 1 9 9 0 - 2 0 0 0
S o u r c e : Own calculations based on OECD Health o f Data 2002.
Som ew hat different picture em erges while investigating the share o f public outlays in G D P (see Tab. 2, Fig. 2). In this situation it is G erm any, France and Sweden that take the leading positions. They have a considerable, 2-percentage point advantage. T he public expenditures on health in Poland and in G reece stand far behind the other countries.
6.5 6,0 5.5 5« 5.0 4.5 4.0
Fig. 2. Share in G D P o f public outlays on health protection in the EU countries and in Poland in the years 1 9 9 0 -2 0 0 0
S o u r с e: A s same as Fig. 1.
In most countries public expenditures constitute a very significant fraction of the total outlays on health protection (see Fig. 3). In line w ith an overall rule characterizing expenditures on health protection, the share o f public outlays in total outlays on this field o f economic activity is higher in high-developed countries than in developing ones. In the so-called high-developed countries this share am ounts to 7 0 -9 5 % , whereas in developing countries it does not exceed 60% . 95 90 85 80 И 75 70 65 60
Fig. 3. Share o f non-public outlays in total outlays on health protection in the EU countries and in Poland in the years 1 9 9 0 -2 0 0 0
Basing on the already presented inform ation, one can state that from am ong all the analysed countries in the period under investigation the highest shares of public outlays in total outlays on health protection have Luxem burg, Sweden, and G reat B ritain, w hereas G reece has the lowest share. Except for the year 1990 (changes o f the political system ) Poland possesses only a slightly low er share than the EU m em ber countries (see Fig. 3).
In the Polish as well as in international statistical system s there exists a division o f the m eans designed for health protection, most generally speaking, into public and into private ones.
The most distinctive change in the expenditures on health protection in the Poland under transition is the change in the relation betw een public and private outlays. The share o f public expenditures is abating, w hereas the share o f households’ outlays is increasing (see Fig. 4). One can thus risk a statem ent that, under sufficiently low level o f G D P per capita, health protection in Poland is too less extent than in other countries financed from public means. The analysis o f non-public expenditures also shows mental changes o f the society. There is a still grow ing b elief in Poland that “one has to possess a big money to be treated” because the health care is more and more often financed out o f the patient’s pocket.
UE a v e r a g e __ —» —Poland
Fig. 4. Share o f private outlays in G DP on health protection in the EU countries and in Poland in the years 1 9 9 0 -2 0 0 0
S o u r c e : A s same as Fig. 1.
One can clearly m ark the period o f transform ation in Poland (the year 1990) follow ed by the introduction o f the act o f Basic H ealth Care. Private expenditures exhibit a grow ing tendency but, if com pared with the EU, Poland starts from a m uch low er level.
In a lot o f cases - quoting W łodarczyk - “the social consciousness petrified inform ation on the outlays on health protection as being 7 0 -1 0 2 USD (year 1993) per cap ita” and in “num erous presentations this sum was [...] confronted with the expenditures, am ounting to thousands o f dollars, incurred by the western countries (W łodarczyk 1998)” . C onducting international com parisons with respect to expenditures expressed in dollars by the official exchange rate is not “a good idea” . It is obvious that exchange rates are determ ined by e.g. international currency market and biased with international trade. T hat is why the nom inal value o f expenditures should be expressed in term s o f purchasing pow er parity (PPP), which allow s for reliable international com parisons. PPP are scaling units o f various countries’ currencies that equalize differences in purchasing pow er o f local currencies due to differences in prices in individual countries.
A nalysing outlays on health protection in terms o f U SD by PPP (see Tab. 3, Fig. 5) one can say that in Poland much less money is spent on health care than on average in the E U m em ber countries. From am ong all the EU countries it is Germ any that assigns the most m eans on health. As far as public expenditures are concerned it is Luxem burg that takes the lead. On the other hand, Portugal and G reece are the countries that spend the least m eans - both total and public - on health.
It follow s from the data reported in Table 3 and in Figure 5 that the share o f public outlays on health protection, expressed in term s o f U SD allow ing for PPP, is in the EU countries low er than in Poland. All in all, analysing expenditures on health, one can state that financing the sphere o f health protection in Poland is at a very low level.
Table 3. Outlays on health protection per capita in U SD in terms o f PPP in the EU countries and in Poland in the years 1 9 9 0 -2 0 0 0
Outlay on health in USD per capita by PPP Countries Years •90 •91 ‘92 •93 ‘94 '95 ‘96 ‘97 •98 •99 •oo Total EU mean 1 189 1 268 1 376 1 427 1 484 1 619 1 690 1 767 1 825 1 943 2 032 Poland 258 296 331 339 349 420 469 461 543 557 587 Public EU mean 942 999 1 073 1 110 1 141 1 226 1 277 1 331 1 374 1 466 1 535 Poland 237 224 253 250 254 306 344 332 355 418 406 S o u r с e: A s same as Tab. 2.
2100 1800 CL CL 1500 CL Ü3 CL 8 <D CL 9 600 co 1200 900 300 0
I h i
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000I total e x p e n d itu r e U E a v era g e □ p u b lic e x p e n d itu r e U E a v e ra g e I to ta l e x p e n d itu r e P olan d □ p u b lic e x p e n d itu r e P olan d
Fig. 5. Share o f public outlays in total outlays on health protection per capita in U S D in terms o f PPP in the EU countries and in Poland in the years 1 9 9 0 -2 0 0 0
S o u r с e: As same as Fig. 1.
3. S p a c e - t i m e m o d e l l i n g o f e x p e n d i t u r e s o n h e a l t h p r o t e c t i o n
The dynam ic model used to model outlays on health protection is the error correction model (ECM ). In such a model the error term is subject to verification and constitutes also a correction factor (explanatory variable) (W elfe (ed.) 2000).
The space-tim e fram ew ork suggested in the paper enables an answ er to the follow ing questions:
- W hat are expenditures on health protection in various countries like? - W hat spatial effects, typical o f individual countries can be observed? - W hat is, com m on for all the countries under investigation, short- and what is long-run elastisicity o f outlays on health protection with respect to G D P like?
The statistical data com e from the annual OECD H ealth 2002 databases and cover the period from 1990 to 2000. This time span was dictated by the changes in the classification o f the collected data after the year 2000 regarding circum stantialities, com parability, unity in classification o f m edical notions, availability and credibility o f data. In the models subject to estim ation there are also som e dum m ies present because o f the existence o f outliers. T he data should
be com parable as they are expressed in terms o f the PPP dollars. T he log- increm ental model has been im plem ented in the space-tim e analysis.
Estimation of the space-time model of total expenditures on health protection (TOT)
As a result o f the conducted analysis the follow ing estim ates have been derived for the T O T model (/-Student statistics are given in parentheses):
M n T O T . = - 0 , 4 2 4 3 - 0 , 2 0 8 4 - (ln T O T ,_x - 0 ,8 5 1 1 - In GDP,_t ) + 0 ,7 7 3 2 M n GD P, +
(-2,297 ) (17,391 ) (IS,142) (9,256;
+ 0,1308- A u stria + 0,1464- B e lg ium + 0,1400- D enm ark + 0,0778- F in lan d + 0,1727- F ran ce +
(5,943 ) (6,508) (6,029) (3.734) (7,087 J
+ 0 ,2 0 2 6 - G erm a n y + 0,1346- G reece + 0,0897• Irela n d + 0,1157• Italy + 0,0584- L uxem bu rg +
(7,821 ) (7,141) (4,732) (5,387) (2.169)
+ 0,1347- H o lla n d + 0 ,1 0 8 5 P o rtu g a l + 0,1007- Spain + 0,1129- S w ed en +
(6.012 ) (6,129) (5,511) (5.130)
+ 0,0875- G rea t B ritain + 0,1397 ■ ( / 3 1 - 0,1202- ( / 62 + 0,0978- U 115 + 0,1264- U 151
(4.315) (4,589) (-4,062) (3,327) (3,755)
Ŕ 1 = 0 ,8 2 2 D W = 2 ,3 7 3
Fig. 6. Total outlays on health protection in the EU and in Poland in the years 1 9 9 0 -2 0 0 0 S o u r c e: A s same as Fig. 1.
T he long-term elasticity o f total expenditures w ith resp ect to G D P equals 0.8511. T he elasticity inform s us that, in the long run, in creasin g G D P by 1% resulted, on average, in a 0.85% rise in outlays on health p rotection. In the short run, outlays on health grow , on average, by 0.77% w ith respect to GDP. Both the estim ates turned out to be statistically significant. T he total o utlays on health p ro tection in G erm any and in F rance are m uch hig h er than the EU mean. L uxem burg is the country o f the least total ex pen d itu res as co m pared to
the EU average. T he outlays on health protection in Poland are far below the EU m ean.
Estimation of the space-time model of public expenditures on health protection (PUB)
As a result o f the conducted analysis the follow ing estim ates have been derived for the PUB m odel (/-Student statistics are given in parentheses):
Д In PU B , = - 0,3683 -0 ,2 9 7 1 - (In P U B , X - 0,8425- In G D P ..) + 0 ,6 6 5 6 A in GDP, +
(-1,796) (16,027) (13,577) (7,139)
+ 0,0052- A ustria + 0,0179- B elg iu m + 0 ,0 5 8 9 -Denm ark - 0 , 0 3 3 1 - Finland + 0 ,0 6 5 2 - France +
(0,474) (1.367) (4,326) (-2,984) (4.772)
+ 0,1013- G erm any - 0,0698- G reece - 0,0150- Ireland - 0,0030- Italy + 0,0145- Luxemburg +
(6.282) (-4.335) (-1,260) (-0,281) (0.979)
+ 0,0032- H ollan d - 0,0287- Portugal - 0,0255- Spain + 0,0325- Sweden +
(0.291) (-2.011) (-2,251) (2.405) + 0,0033- G reat Britain + 0 ,1 5 5 0 -£/31 - 0 ,1 3 5 9 -U 62 (0.306) (4,158) (-3.737) Ŕ 2 = 0 ,8 1 6 D W = 2 ,8 2 5 0,1 0,05 0 -0,05 -0,1
Fig. 7. Public outlays on health protection in the EU and in Poland in the years 1 9 9 0 -2 0 0 0 S o u r c e : A s same as Fig. 1.
In the case o f the equation describing the increm ent in public expenditures on health protection, the long-term elasticity o f the expenditures w ith respect to G D P equals 0.8425. T he elasticity informs us that, in the long run, increasing GDP by 1% resulted, on average, in a 0.84% rise in outlays on health protection. In the short run, outlays on health grow, on average, by 0.67% w ith respect to GDP. T hus the effect o f the GDP im pact is less than proportional. On the basis of the obtained outcom es, one can state that, in the short run, m uch less money was spent on health protection than in the long run. Both the estim ates turned out
to be statistically significant. The public outlays on health protection in Germ any and in France are m uch higher than the EU mean. G reece is the country o f the least public expenditures as com pared to the EU average. T he public outlays on health protection in Poland exceed the EU mean.
Estimation o f the space-time model of private expenditures on health protection (PRYW)
As a result o f the conducted analysis the follow ing estim ates have been derived for the PRY W model (/-Student statistics are given in parentheses):
A in P R YW , = - 2 ,8 6 9 4 - 0 ,6 3 4 6 - (/л PRYW ,_X - 1,0581-/« G D P,^ ) + 0,6281 - A in GDP, +
(-5,496) (7,313 J (16,416) (2,909)
+ 0,1154- A u stria + 0,1996- B e lg ium - 0 ,1 5 6 8 - D enm ark - 0 ,0 2 7 8- F in lan d + 0 ,1 0 9 5 ■ F ran ce +
(4,543 ) (6,642) (-5,526) (-1,178) (4,192)
+ 0,1223- G erm a n y + 0,4 6 0 8 - G reece + 0,0096- Irela n d + 0,0 5 4 2 - Italy - 0 ,9 2 0 0 - Luxem bu rg +
(4.651 ) (9.506) (0,387) (2,242) (-10,628)
+ 0,1850- H o lla n d + 0 ,2 6 9 6 - P o rtu g a l + 0,0702- Spain - 0 ,2 6 4 2 - S w ed en +
(6,577) (7,410) (2,828) (-8,145)
- 0 , 2 6 8 3 - G r e a t B ritain (-8,351)
Л 2 = 0 ,8 6 7 D W = 1,593
Fig. 8. Private outlays on health protection in the EU and in Poland in the years 1 9 9 0 -2 0 0 0 S o u r c e : A s same as Fig. 1.
In the equation describing the increm ent in private expenditures on health protection, the long-term elasticity o f the expenditures w ith respect to GDP equals 1.0581. The elasticity inform s us that, in the long run, increasing G D P by 1% resulted, on average, in a 1.06% rise in outlays on health protection. In the
short run, outlays on health grow, on average, by 0.63% with respect to GDP. Both the estim ates proved to be statistically significant. T he private outlays on health protection are much higher in G reece, whereas in Luxem burg much lower than the EU mean. T he private outlays on health protection in Poland are at alm ost the same level as the EU average, being only slightly lower.
It is w orth stressing that in each o f the presented m odels the increm ents were used instead o f the levels o f the variables. To much extent this type o f m odels elim inates the possibility o f the occurrence o f spurious correlations. A nother im portant feature o f this class o f m odels is that they exclude the occurrence of non-stationarity or autocorrelation. However, their shortcom ing is a poor goodness o f fit. T he low value o f the coefficient o f determ ination is caused by the transform ations o f variables used in the model (increm ents o f logarithm s).
3. C o n clu sion s
At the beginning o f the 90s there increased the num ber o f countries that looked afresh at their national accounts. The countries w ere searching for a strategy that would allow them to pursue adequate health policies; to get versatile and internally consistent health accounts as well as general national health inform ation system s. The broader outlook on the issues related to public health contributed to changes in the existing statistical system s o f health care. T he new inform ation system s connect in unity socio-econom ic factors o f secondary im portance (econom ic, social and physical environm ent) with the data on expenditure and financing of health care service. The System o f Health A ccounts prom pts the International C lassification o f Health A ccounts that covers three issues: functions o f health care; providers o f health care service; sources o f finance o f health care. T he suggested accounts enable com parisons both in term s o f tim e and in term s o f space for individual countries. They serve the purpose o f international com parative analyses o f various organizational and financial aspects o f health care.
Recently, in num erous countries belonging to the EU, a change in their attitude tow ards finance o f health care sphere has been observed. Private expenditures are gaining a higher and higher share in the total expenditures on health protection. T his can be attributed to changes in the social m entality as well as to the w elfare effect and to the existing insurance system s. In a lot of countries, independently o f their m ethods o f financing health care, there dim inished the expenditures - m easured as a fraction o f G D P - on public health protection in favour o f private outlays.
T o sum up, it follow s from the conducted investigation that there is strong dependence betw een expenditures on health protection and the econom ic environm ent expressed by G ross Dom estic Product.
In the EU countries as well as in Poland expenditures on health protection constitute essential goods. Total and public expenditures are norm al goods both in the short and in the long run, whereas private outlays are norm al goods only in the short run. H ow ever, in the long run, private expenditures on health are perceived as luxurious goods.
B asing on observations and on researches being conducted, one is allow ed to state that the best-suited model for the sake o f space-tim e analyses is the error correction model.
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W Y D A T K I NA O C H R O N Ę ZD R O W IA W PO LSC E I UNII E U R O P E JS K IE J - A N A L IZA PR Z E ST R Z E N N O -C Z A SO W A
W krajach O ECD opieka zdrowotna jest jednym z największych i najbardziej dynam icznie rozwijających się sektorów gospodarki narodowej, którego finansow anie jest coraz bardziej złożone, a którego analizy finansowania są niezw ykle ważne z praktycznego punktu widzenia.
Jednym ze sp osob ów porównywania wydatków na ochronę zdrowia pom iędzy poszczególnym i krajami jest ustalenie w spólnych, dla tych państw, sp osob ów klasyfikacji wydatków zdrowotnych. M iędzynarodow e porównania w tym zakresie są m ożliw e przy wykorzystaniu N arodow ego Rachunku Zdrowia (NH A). System Rachunków Zdrowia (SH A ) został zalecony przez E U R O ST A I i OECD krajom członkow skim w celu wsparcia prawidłowej analizy danych.
W wyniku zmian zachodzących w poszczególnych państwach niezbędne stało się, m iędzy innymi, określenie now ego zapotrzebowania na informacje w system ie opieki zdrowotnej oraz ustalenie now ych reguł zbierania i korzystania z danych tak, aby stanow iły one dla osób zajmujących się opracowaniem i wdrożeniem polityki zdrowotnej podstawę do podejm owania określonych decyzji. Informacje uzyskane z narodowych rachunków m ogą ułatwić podejm ow anie decyzji makroekonom icznych dotyczących alokacji źródeł finansowania dla całego sektora opieki zdrowotnej. Ich konstrukcja um ożliw ia również dokonyw anie analizy porównawczej wydatków zdrowotnych w innych krajach.
Przy porównaniach m iędzynarodowych całkowitych wydatków na ochronę zdrowia niezw ykle istotną sprawą je st przeliczenie tych wydatków na liczbę ludności danego państwa oraz określenie waluty (np. U S D ) i podanie ich w odniesieniu do ich siły nabywczej, bądź też jako procent produktu krajowego brutto.
Biorąc pod uwagę aspekty prawne i organizacyjne oraz dostępność danych statystycznych w artykule zaprezentowano wyniki analiz przestrzenno-czasowych.
