8. International figures

Alongside total health and social care expenditure, CBS also publishes a figure for expenditure on healthcare. This is the internationally comparable figure in accordance with the System of Health Accounts and comprises medical care, rehabilitation care, long-term healthcare, support services, medicines and medical goods, preventive care and policy and management of the healthcare system. 

The following components are not included in the international figure but are included in the national figure: long-term social care (primarily home care and support), social work activities, children's day care, training and R&D expenditure. 

The international figures are broken down along three axes: providers (HP: health providers), financing (HF: health financing), care function (HC: health functions). With new sources such as claims under the Healthcare Insurance Act and Long-term care Act (Wlz) claims becoming available, CBS has improved both the allocation of financing to providers and the allocation of expenditure to functions of health and social care in the figures after revision. In addition, the change of provider categories following the revision also has an impact on the allocation of HP categories. 

The international functions of health and social care have been agreed internationally (OECD-Eurostat-WHO) and are therefore a compromise, aimed at international comparability. In the functions of health and social care, there is a strong focus on the setting in which the care is provided: residential, day care, ambulatory or at home. With regard to care types, setting has a less prominent role. When operationalising the figures by function, CBS takes the care type as its starting point. With the help of supplementary information such as microdata on claims and indications, the care types are then broken down by setting, for example for perinatal care, care for the disabled and (geriatric) rehabilitation care. The relationship between the international functions of health and social care and the care types is explained further in annex 2.

8.1 Expenditure on healthcare 2021, before and after revision

The figure for total expenditure on healthcare, in accordance with the internationally comparable definition, is €3.3 billion higher after revision. The figures before and after revision are published in the table below, broken down by function. The most important changes are described beneath the table. 

• Major shift from ‘In-patient curative care’ (HC.1.1) to ‘Specialist outpatient curative care’ (HC.1.3.3). The distribution of medical specialist care between inpatient care, day treatment and outpatient care was already based on Zvw claims before the revision. An important change relates to the expenditure on expensive medicinal products: whereas previously they were distributed using the same general distribution key, they are now entirely allocated to ‘Specialist outpatient curative care’ (HC.1.3.3).
• Major shift from ‘Day cases of curative care’ (HC.1.2) to ‘Specialist outpatient curative care’ (HC.1.3.3). Previously it was assumed that all care provided by private clinics and independent treatment centres consisted of day treatments. However, the independent treatment centres’ claims reveal that the care provided is largely outpatient care. Similarly in curative mental health care, based on older sources, a significant proportion of expenditure was attributed to day treatments. However, consultation with experts from sector bodies reveals that day treatments barely occur in curative mental health care. In addition, since the introduction of the Care Performance Model (‘Zorgprestatiemodel’), the only differentiation that can be made in curative mental health care is between consultations and residential care, which means that curative mental health care falls exclusively under ‘In-patient curative care’ (HC.1.1) and ‘Specialist outpatient curative care’ (both HC.1.3.3 and HC.1.3.9). Those consultations which coincide with residential care are assigned to ‘In-patient curative care’ (HC.1.1).
• The further rise in ‘Specialist outpatient curative care’ (HC.1.3.3) is largely the result of improved coverage of the ‘Specialist medical practices and outpatients’ clinics’ subclass (SBI 86221), which has yielded a better picture of expenditure on insured and uninsured outpatient care.
• Sharp rise in ‘Other outpatient curative care’ (HC1.3.9). The increase is primarily the result of improved coverage of subclasses such as ‘Other paramedical practitioners’ (SBI 86919) and ‘Practices of psychologist’ (SBI 86913). Not all activities of psychologist practices are deemed to be healthcare; psychological assistance care is classified under social work activities, and as such falls outside the System of Health Accounts.
• Major shift from ‘Long-term social care cash benefits’ (HCR.1.2) to ‘Long-term nursing care [health]’ (HC.3.4). The personal budgets (cash benefits) under the Wlz which accrue to ‘Households’ (HP.8) were previously assigned to ‘Long-term social care cash benefits’ (HCR.1.2), with the assumption being that the bulk is long-term social care. Thanks to an improved linkage, we observe that a large proportion of these personal budgets in fact do not accrue to households but to other providers, including ‘Secondary providers of healthcare’ (HP8.2) and ‘Rest of the world’ (HP.9). For this reason, this expenditure is now classified as ‘Long-term nursing care [health]’ (HC.3.4).
• Sharp fall in ‘Support services’ (HC.4). Analyses of the annual accounts of independent laboratories reveal that they primarily supply services to other healthcare providers (see 6.1 Examples of double counting). This has led to a correction in order to prevent double counting, which has resulted in a fall in expenditure on ‘Laboratory services’ (HC.4.1). In addition, it has been determined that the expenditure previously assigned to ‘Imaging diagnosis’ (HC.4.2) largely relates to R&D activities, which do not belong under health expenditure.
• Sharp rise in Preventive care (HC.6). The increase is primarily explained by a broader allocation of preventive dental care. Whereas previously only dental care for under 18s (reimbursed under the Zvw) was allocated to ‘Preventive care’ (HC.6), now preventive activities for adults, such as x-rays, check-ups, diagnostics and oral hygiene, are also classified under ‘Preventive care’ (HC.6). In addition, dietary advice has been more accurately catalogued thanks to a refined classification of dieticians’ practices and improved coverage of the ‘Paramedical’ subclass (SBI 86919). Improved coverage of the SBI subclass ‘Preventative health care (no health and safety at work)’ (86923) has also contributed significantly to the increase in expenditure in this category. Finally, a shift is taking place from ‘Health promotion, multi-sector’, (HCR.2) to ‘Preventive care’ (HC.6).
• Sharp increase in ‘Healthcare n.e.c.’ (HC.9). The significant increase in this category is due to the fact that more detailed distribution keys have been used (based on microdata) in order to more accurately determine what expenditure cannot be specifically assigned to a care type. Previously, this expenditure was distributed across different functions of health and social care but it is now explicitly classified as ‘Healthcare n.e.c.’ (HC.9). This relates primarily to items for which the applicable function is not known, such as ‘Other care revenue’ and ‘Subsidies’.
• There is no longer any expenditure reported under ‘Health promotion, multi-sector’ (HCR.2). Because only the Ministry of Health, Welfare and Sport-funded part of the NVWA’s costs is now included following the revision, this portion has been assigned to ‘Preventive care’ (HC.6). 

New classification of actors based on HP classification

With the introduction of a new classification of actors within the Health and Social Care Accounts (see The new classification of care and social care providers), adjustments have been made to align them with the international classification of providers (HP classification). The main changes are:

1. Independent psychiatrists have been included in the more comprehensive ‘Ambulatory mental health care and psychiatrists’ actor, moving from ‘Medical practices’ (HP.3.1) to ‘Ambulatory health care centres’ (HP.3.4).
2. Umbrella organisations in the field of health care have been moved from ‘Other administration agencies’ (HP.7.9) to ‘Ambulatory health care centres’ (HP.3.4).
3. Several existing and new actors have been assigned to ‘Secondary providers of health care’ (HP.8.2). They include retailers of medicaments, welfare institutions for the elderly, children's day care centres, local welfare work and other secondary healthcare providers because they all provide health care as a secondary activity.

The table below shows the figures before and after the revision, with the new classification of actors based on the HP classification being applied in both cases. The differences are largely explained by the factors elucidated previously regarding health and social care expenditure (see 7. Health and social care expenditure). For this reason, the causes of these differences are only touched on briefly in the text below. 

A complete allocation of the 73 actors based on the HP classification may be found in annex 1.

• Major shift from ‘Medical practices’ (HP.3.1) to ‘General and university hospitals’ (HP.1.1). Fees for the work of independent medical specialists and dental specialists in hospitals are now allocated to hospitals. The decrease in ‘Medical practices’ (HP.3.1) is largely offset by improved coverage of the ‘Specialist medical practices and outpatients’ clinics’ subclass (SBI 86221), which has yielded a more complete picture of expenditure on insured and uninsured outpatient care.
• Decrease in ‘Long-term nursing care facilities’ (HP.2.1). Due to the use of microdata, it is now possible to draw a clearer distinction between ‘Long-term social care’ (HCR.1) and ‘Services of long-term nursing care’ (HC.3). This means that a larger share of Wlz expenditure is assigned to ‘Long-term social care’ (HCR.1), resulting in a fall in expenditure for this provider type. This shift is slightly offset by the fact that more Wlz personal budgets (cash benefits) are allocated to these providers, leading to an increase in ‘Home care’ (HC.3.4).
• Increase in ‘Facilities for the disabled’ (HP22-29). For this provider type, the use of microdata to differentiate between ‘Long-term care (social)’ (HCR.1) and ‘Long-term nursing care’ (HC.3) results in a larger share being allocated to healthcare.
• Sharp fall in ‘Medical practices’ (HP.3.1). Previously, claims for GP care were functionally allocated to the ‘General medical practices’ actor and those for multidisciplinary care to ‘Partnerships’. In the new figures, the claims are allocated to the actors submitting them, which means a significant share falls outside ‘Medical practices’ (HP.3.1).
• Decrease in ‘Dental practices’ (HP.3.2). As in the case of GP care, claims for dental care were previously functionally allocated to the ‘Dental practices’ actor. Now they are allocated to actors that submit claims for care, even if they fall outside the ‘Dental practices’ subclass (86231).
• Sharp rise in ‘Other health care practitioners’ (HP.3.3). The increase is the result of improved coverage of the SBI subclasses ‘Practices of psychologist’ (86913) and ‘Other paramedical practitioners’ (SBI 86919), including alternative healers.
• Increase in ‘ Providers of home health care services’ (HP.3.5). Due to improved coverage of the subclasses for ‘Residential and day care for the disabled’ (SBI 8720, 87301) and ‘Residential care for the elderly’ (SBI 8710, 87302), combined with the use of Zvw and Wlz claims, we have now achieved more accurate insight into the revenue from micro-institutions outside the Care Institutions statistics.
• Sharp fall in ‘Laboratories, other ancillary services’ (HP.4.2-4.9): Analyses of the annual accounts of independent laboratories reveal that they primarily supply services to other health care providers, which has led to a correction for double counting and a fall in expenditure on ‘Laboratory services’ (HC.4.1).
• Sharp fall in ‘Pharmacies’ (HP.5.1) and ‘Suppliers of medical appliances’ (HP.5.2): Previously, claims for prescription medicaments and medical goods were allocated to the actors ‘Pharmacies’ and ‘Suppliers of medical appliances’ by default. Now those claims are allocated to the actors which actually submit them. An exception to this are Wlz-financed medical goods, which, in the absence of better options, remain allocated to the actor ‘Suppliers of medical appliances’.
• Increase in ‘Providers of preventive care’ (HP.6): The increase is the result of improved coverage of the SBI subclass ‘Preventative health care (no health and safety at work)’ (86923).
• Small increase in ‘Other administration agencies’ (HP.7.9). The amount assigned to this category after the revision consists of care provided by the actor ‘Umbrella organisations in the field of health care’.
• Increase in ‘Households’ (HP.8.1): The amount assigned to ‘Households’ after the revision consists of expenditure from personal budgets (cash benefits) under the Zvw. Before the revision, this was incorrectly assigned to ‘Long-term social care cash benefits’ (HCR.1.2).
• Very sharp increase in ‘Secondary providers of health care’ (HP.8.2). The use of claims (and personal budgets), linked to the business register, reveals that significantly more healthcare is supplied by secondary providers of healthcare than had previously been assumed.