Malta Health Profile 2012

The Maltese health care system is commendable for its equity and comprehensive coverage for all citizens. Over the years it has developed innovative services offered free of charge to all those who require them. In spite of the fact that Malta has a small population with highly limited resources the health care system offers a highly comprehensive service. The major challenges facing health care in Malta are ensuring sustainability of the system, developing micro-efficiency and building mechanisms to measure quality and outcome. The reform process, based upon objectives drawn up in 1993, has commenced but is proceeding slowly. It is important that implementation of the necessary reforms continues in order to ensure that the health care system attains the identified health policy goals. A policy framework, launched in 1995, identifies the key diseases and risk factors that must be targeted  to achieve the desired health gains. Indicators of health status in Malta are generally favourable. The public health service is well established and the population approach towards health gain based on health promotion and disease prevention will be sustained paying particular attention to the target areas.
The goal of efficiency is currently a priority throughout the public sector in Malta. Health care expenditure, both public and private, has shown an upward trend. Whilst public expenditure is controlled by budgetary capping, private health care expenditure may continue to grow exponentially if present trends persist. Within state health care, the reforms of management structures and the establishment of systems for accountability are being carried out to improve micro-efficiency. This requires the support of information technology and personnel training. Techniques that are known to reduce lengths of stay are available and their use needs to be consolidated. However for hospitals to be able to function more efficiently, staff incentives linked to performance must be introduced.

Inappropriate utilization of acute hospital services needs to be tackled. For this to diminish a strong primary and community care service is required. Reform in this sector is urgently needed alongside the development of community services. Both are necessary to ensure that the needs of the growing elderly and frail population are met appropriately by the health care system. The widespread availability of private health care services and the opening of private hospitals since 1995 has greatly enhanced consumer choice. In private health care, consumer choice is virtually unlimited both for primary and specialist care as there is no gatekeeper function. Choice in the public sector is somewhat restricted in terms of facilities due to Malta’s size. It would not be cost-effective to have several hospitals and specialists who perform highly specialised procedures. Otherwise patients are offered a choice of specialist in most areas of hospital care. In primary care the public system does not guarantee consumer choice and this is one of the major issues that will be addressed in the reforms. The involvement of patient groups as partners in developing policy is gradually being established.
One of the major strengths of the health care system is the highly professional and dedicated health care workforce. However the very high standards of clinical care are often compromised by environmental constraints such as hospital overcrowding in winter. This problem can only be overcome by intersectoral collaboration with social care providers for the elderly, as well as by ensuring an adequate gate-keeping function exercised by a strong primary health care system. The professional regulatory boards serve to monitor ethical and professional standards. However the Ministry of Health needs to transform itself from direct provider of services to regulator. It must develop its role as auditor and must establish effective quality assurance mechanisms. It must also strengthen its role as regulator for the private sector especially in view of the recent increase in private health care delivery. A holistic approach to health care reform is being pursued. Collaboration between primary care and hospital care services together with the support from the well developed public health services will be necessary to ensure that the health care system develops in a sustainable manner in the coming years.

HEALTH AND DE VELOPMENT
The Ministry of Health has been undergoing organizational changes since 2004. The intention was to strengthen its role in health protection and its regulatory and monitoring functions, and to differentiate the role of policymaking and regulation from that of providing services. The administrative reform was well advanced in 2006. Published in 1998, the national health policy document, Health Vision 2000, listed coronary heart disease, stroke, lung cancer, breast cancer, diabetes, mental health and road traffic accidents as priorities. Asthma was subsequently added to the list. Smoking, obesity, high blood pressure, serum cholesterol and inadequate physical activity were identified as the most important risk factors. In 2003 and 2004 respectively, a national health interview survey and a national public health report were published. Policy evaluation and the further development of the national health policy represent an important area for future work. Other ministries as well as stakeholders outside the administration are becoming increasingly involved in the policy development process. EU accession has been a major policy driver.
Health care in the public sector is highly centralized and regulated. Health care is provided through two systems: statutory and private. With respect to quality of care, in addition to the lack of standards and procedures, there are problems related in particular to administrative matters and to the lack of a gatekeeping system, which promotes an overutilization of secondary care services. Collaboration between the private and public sectors is still not very effective and the private sector remains largely unregulated. In 1995, regulations on licensing private clinics according to facilities and staffing were introduced. It is planned to revise these regulations to include public clinics and governance of quality care.
The Government focuses on quality of care as a priority. Decentralization of the public health care system has been high on the agenda since the early 1990s. The traditionally highly equitable health system faces a gap between available funds and increasing demands. Expenditures on pharmaceuticals have risen in recent years and cost control is a main concern of the Government. Mater Dei Hospital. In the early 1990s, Malta decided to build a state-of-the-art acute care hospital that was also a specialist research and teaching facility. The construction of the Mater Dei Hospital and procurement of the necessary equipment received primary attention whereas health care, in particular primary health care and mental health, was neglected owing to financial restraints. The opening of the Hospital was planned for 2005 but postponed several times. It is hoped that this can take place in 2007. In the mid-1990s, the costs were estimated at Lm 50 million, but the current estimate is three times as high. The pharmaceutical sector has undergone major reform. A Medicine Act approved in 2002 laid the foundation for a new pharmaceutical policy and more visible regulation. Malta is almost entirely reliant on the importation of medicines from overseas. Manufacturers need to undertake difficult restructuring and quality improvement processes in order to fulfil the requirements of Good Manufacturing Practice and to bring their marketing in line with EU regulations. Importers and distributors have strongly resisted the system of product registration and market authorization set up by the newly established Medicines Authority. Malta was given a four-year transition period by the EU. The number of products on the market is markedly reduced and, as cheaper products from African countries have left the market, prices have increased remarkably. There is no national system of price control for pharmaceuticals. Prices of pharmaceuticals purchased from community retail pharmacies seem high compared to the European scale. Malta has a positive list of medicines.
Disease prevention and control remains a major public health challenge. Circulatory diseases are the leading cause of death. Malta ratified the WHO Framework Convention on Tobacco Control in 2003 and the amended Smoking in Public Places Regulation came into force in 2004. There are no national screening programmes, not even for cancer. The rate of childhood obesity is one of the highest in the world. Malta is hyperendemic for meningococcal diseases, with a marked increase from 1994 to 2000 (World Health Report, 2006). Since 2001, the incidence has been slowly decreasing but remains high compared to most EU countries.

Environmental factors constitute important health risks. Bronchial asthma is more frequent in Malta than in other parts of Europe. The high prevalence of the disease is partly explained by the hot and humid climate, genetic predisposition and high smoking rates, which increase environmental tobacco smoke. Health professionals report the problem of non-compliance of asthma patients in taking medication, which sometimes causes failures in asthma control.