We adhered to the OECD methodology on health accounts SHA 1.0 [20] and its revisions SHA 2011 [19]. This methodology constructs the accounts from three different perspectives: health care functions (ICHA–HC, Table 1), provider industries (ICHA–HP, Table 2), and payers (ICHA–HF, Table 3). Each of the perspectives divides health care expenditures into individual chapters according to a different criterion. The health care function account attributes expenditures for example to services of curative care, and rehabilitative care. The provider industry perspective sorts expenditures according to the type of facility within which they were incurred, including hospitals, or providers of ambulatory care. The health care function account as well as the provider industry account include also chapters on medical goods provision, prevention, and health care administration. The perspective of payers categorizes expenditures according to who incurred them into the chapters of government and compulsory health insurance financing schemes, voluntary financing schemes, and household out-of-pocket payment.
Table 1 Mental health expenditures by the OECD ICHA-HC classification of health-care services/functions, Czech Republic, 2015 Table 2 Mental health expenditures by the OECD ICHA-HP classification of health providers, Czech Republic, 2015 Table 3 Mental health expenditures by the OECD ICHA-HF classification of health-care financing, Czech Republic, 2015 Several remarks are needed as far as the construction of our accounts is concerned. The methodology sometimes asks for a higher degree of disaggregation than we were able to achieve; when this is the case, the table shows not disaggregated (ND) for the respective subchapter. We also had to address the changes brought by the revised version of the methodology SHA 2011. First, the SHA 2011 renames some chapters and subchapters, and slightly changes the structure of the accounts. We reassigned the 2006 expenditures to facilitate comparisons. Second, paying greater attention to social services provided to patients, SHA 2011 introduces a new chapter long-term social care (HCR.1). This expands the calculated size of the total health care budget. To allow comparability with the 2006 figure, we report both the 2015 share of mental health expenditures in the total health expenditure including the new chapter (SHA 2011) as well as the share in the total expenditure that excludes it (SHA 1.0).
In addition to the OECD methodology, we further classify expenditures according to groups of related diagnoses (Table 4). These groups are based on the internationally recognized 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) [21]. Lastly, we also consider the perspective of inputs entering production of health care services (Table 5). The complete methodological procedure and results are available in Online Resource 1.
Table 4 Mental health expenditures by the ICD-10 diagnostic groups and by health Provider, Czech Republic, 2015 Table 5 Mental health expenditures by cost category, general and mental health hospitals only, Czech Republic, 2015 Data
The main data sources are public reports collected from the General Health Insurance Fund (GHIF), the Czech Statistical Office (CSO), and The Institute of Health Information and Statistics of the Czech Republic (IHIS). These resources were complemented by unpublished information from the Ministry of Health of the Czech Republic and GHIF. GHIF is the largest health insurer in the Czech Republic. Two thirds of the population are enrolled with this insurer, which provides a certain guarantee of representativeness [22]. The insurer annually publishes a comprehensive yearbook [23] with a detailed description of enrolees, collected premiums, services provided by contracted health facilities, and related expenditures. This document specifies total expenditures, expenditures on psychopharmaceuticals, and expenditures on rehabilitative spas. The GHIF further provided unpublished financial data on ambulatory psychiatric care, psychiatric hospitals, and psychiatric departments in general hospitals as well as the relative resource consumption by each diagnostic group. The CSO annually publishes accounts based on the OECD methodology for the entire national system of health care [11]. For our analysis, we use the information about total health care expenditures and expenditures on health administration contained in these accounts. In 2013, IHIS reported the structure of costs for selected types of health care establishments that serves as a basis for our input category perspective [24]. The results are converted from Czech korunas (CZK) to euro (EUR) with the annual average of the daily nominal exchange rate in 2015: EUR 1 = CZK 27.283 [25].
Mental health expenditures are defined as health expenditures on services for patients with primary or first-listed diagnoses from Chapter V, Mental and Behavioural Disorders (F00-F99), of the Tenth Revision of International Classification of Diseases (ICD-10). By this definition we exclude expenditures on somatic illnesses that can be partially a consequence of mental health conditions (for example cirrhosis of liver as a consequence of alcohol addiction). The study further excludes disability pensions, sickness benefits, and also services for the mentally ill that are considered as social services in the Czech context. Such types of expenditures are financed from social care budgets, mainly by central and local governments. Unfortunately, there is no reliable data source that would allow us to identify the share of the social care budget allocated to mental health issues. Due to a lack of reliable data, the study also excludes services for the mentally ill provided by general practitioners.
Health Care Function Perspective (ICHA-HC)
The health care function perspective allocates expenditures to the following chapters and subchapters that are applicable in the context of the Czech Republic: curative care (chapter HC.1, subchapters HC.1.1 inpatient curative care in psychiatric and general hospitals and HC.1.3 outpatient curative care), rehabilitative care (HC.2, subchapter HC.2.1 inpatient rehabilitative care), ancillary services (HC.4, subchapter HC.4.3 patient transportation), medical goods (HC.5, subchapter HC.5.1 pharmaceuticals and other medical non-durable goods), and governance and health system financing and administration (HC.7, data not disaggregated into subchapters). Rehabilitative care refers in the Czech context to health spa. Patient transportation includes emergency cases only. Medical goods denote outpatient pharmaceuticals while inpatient pharmaceuticals are a part of inpatient expenditures.
First, we calculated the shares of particular functions on the total yearly expenditures of GHIF (from both published [23] and unpublished sources). The sum of these shares gives a relative proportion of mental health care expenditures to total health care expenditures. Second, assuming that for other insurers and sources of financing the shares are equivalent, we subsequently applied them to the total national health care expenditures reported by the CSO [11] to get mental health expenditures for the whole system. Expenditures on preventive care (chapter HC.6 of ICHA–HC), long-term social care (chapter HCR.1), health promotion (chapter HCR.2), investments, education, and research and development (chapters R.1, R.2, R.3) were excluded from the amount of total health care expenditures. The reason is that most of these chapters are complementary to health care expenditures rather than constituting their organic part. Moreover, we expect a large heterogeneity in spending across particular health care fields within these chapters. Consequently, applying the assumption that expenditures on these chapters correspond to the fraction of the total budget of GHIF consumed by mental health care would mislead the results. On the other hand, we consider reasonable to apply this assumption to mental-health care administration (chapter HC.7) as there is no compelling reason why mental-health care administration should be differently demanding than administration in other health care fields.
Provider Industry Perspective (ICHA-HP)
To categorize expenditures according to provider industries, figures on health care functions were clustered together according to institutional settings in which care is provided. The most relevant chapters are hospitals (HP.1) and providers of ambulatory health care (HP.3). Hospitals are further subdivided into general hospitals (HP.1.1), psychiatric hospitals (HP.1.2), and health spas (coded as specialized hospitals HP.1.3). The ambulatory care provided in hospitals is allocated to subchapter HP.1.1 and ambulatory care provided by independent medical practices is allocated to subchapter HP.3.1. The chapters representing providers of medical goods (HP.5) and health administration (HP.7) display the same figures as the corresponding chapters under the health care function perspective.
Payer Perspective (ICHA-HF)
To offer the payer perspective, we start from the CSO classification of national health expenditures by the type of the financing entity. The applicable chapters are government schemes and compulsory contributory health care financing schemes (HF.1, subchapters HF.1.1.1/2 government schemes further divided to the central and local government schemes, and HF.1.2 compulsory contributory health insurance schemes), voluntary health care payment schemes (HF.2, subchapters voluntary health insurance schemes HF.2.1, non-profit financing schemes HF.2.2, and enterprise financing schemes HP2.3), and household out-of-pocket payment (HF.3).
We assume that the shares of different budgeting segments are the same for the mental health care accounts as for the general health care accounts. We calculate the share of each budgeting segment and apply it to the national expenditures on mental health care.
Diagnosis Perspective
An unpublished data from GHIF shows how its reimbursements to providers of mental health care are divided among different diagnostic groups. We consider separately outpatient medical practices (HP.3.1), psychiatric departments of general hospitals (HP.1.1), psychiatric hospitals (HP.1.2) and providers of medical goods (HP.5). To extrapolate the information to the whole system, we multiply the estimates of expenditures on a given provider industry from the table ICHA-HP with the share that each diagnostic group consumes according to GHIF.
Input Costs Perspective
To divide expenditures according to input categories such as labour or material, we use shares of inputs published by IHIS in 2013, which cover psychiatric as well as general hospitals. We assume that shares of input costs at psychiatric departments of general hospitals correspond to the shares of input costs at general hospitals as a whole. Expenditures on inputs for psychiatric hospitals and departments are then calculated by division of expenditures per a type of provider in 2015 according to the shares published by IHIS.