Santé et Services sociaux Québec.
Previous page Adjust text size

Brief analytical summaries or syntheses #31

Improving estimates of exports and imports of health services and goods under the SHA framework


This document is the final report of an OECD project that responds to increasing demand for statistics on the trade in health care goods and services. The report provides clear concepts, definitions and guidelines for the production of reliable, timely and comparable estimates of imports and exports of health services and goods within a standard health accounting framework.


Trade in health services, and its best-known component, medical tourism, has attracted a great deal of media attention in recent years. This creates the impression that a large part of the population is regularly seeking health care abroad or buying pharmaceuticals over the internet from foreign providers. The apparent growth in such imports and exports has been fuelled by a number of factors. Technological advances in information systems and communication enable patients or third party purchasers of health care to seek out quality treatment at lower cost and/or more quickly from health care providers in other countries. An increase in the portability of health coverage, whether as a result of regional arrangements with regard to public health insurance systems or developments in the private insurance market, is also poised to further increase patient mobility. All this is coupled with a general increase in the temporary movement of populations for business, leisure or specifically for medical reasons between countries.

Analysis and results

Many scholarly articles and studies concur that there is a lack of hard data on the extent of the provision of services across borders. Much of the evidence is anecdotal and incomplete. However, as agreements on cross-border movement come into force and effects on domestic or regional health systems potentially increase, the need to collect comparative data and monitor trends becomes more pressing.

A System of Health Accounts (SHA) provides a standard accounting framework for the comparable measurement and reporting of health expenditures by a country’s resident population. Most OECD and European Union countries have already implemented national health accounts according to the SHA methodology. In theory, this includes reporting of health care goods and services acquired from foreign health care providers – whether hospitals or dentists abroad, or retail internet pharmacies based in another country. In practice, reporting has been scarce due to a lack of guidance on the specific concepts, definitions and potential sources of information. The original SHA manual, published in 2000, does not provide any mechanism for explicitly reporting exports of health care goods and services in the standard tables.

The OECD undertook this project, called “Improving estimates of exports and imports under the SHA framework” to provide definitions, concepts and guidelines to help meet the growing need for comparable and timely statistics on the international trade in health. The phases of the project took existing statistical frameworks as their starting point for drawing up a conceptual framework and commissioned a number of country case studies to ascertain current practices and potential sources of information on which to base the guidelines for SHA compilers.


The aim of the project was to set in place the framework and guidelines for future reporting of imports and exports of health services. The availability of data in this arena remains patchy. Existing health accounts collections and the questionnaire used in the latter stage of the project revealed that for the vast majority of countries the level of trade in health care remains marginal – typically accounting for 0.0 to 1.0% of total health spending (though this is likely underestimates the real extent of trade). Trade is more important for some of the smaller member states where there is a greater need to source care — in particular certain specialist treatment — abroad.

Implications and recommendations

In developing the final guidelines, much of the debate focused on the issue of residency and the treatment of particular population groups such as retirees and refugees. The issue of retirees is particularly important in the EU and for U.S. Medicare retirees abroad.

Technically, retirees abroad are no longer part of the resident population and therefore should not be considered in a country’s health spending estimate, even though their health spending is still covered under their original health insurance. In the case of refugees or persons without clear residential status, there may in some circumstances be spending on health care which, although in theory is not linked to residency, could be considered an obligation of the host country and thus should be included. In both cases, there was broad agreement that while such definitions should be adhered to as closely as possible, there had to be some flexibility to account for specific circumstances.

Many other services linked to health travel are borderline or lie outside the definition of health care (e.g. cosmetic surgery, patient transport abroad, etc.). It was recommended that the accounting of imports and exports should be consistent with the guidelines set out in the rest of the SHA manual.

On the question of draft guidelines and recommended data sources, it was recognized that, as with many areas of health accounting, no single set of circumstances could apply to all countries or to all statistical systems. As such, the guidelines should present an array of possible sources and methodologies, perhaps with some indication of preferred methods or sources. Finally, it was proposed that in many cases the reporting of imports and exports, certainly at an initial stage, should be partial, beginning with some of the priority areas such as the exclusion of exports of hospital service from overall health expenditures.


Improving estimates of exports and imports of health services and goods under the SHA framework