State of Health in the EU Country Health Profile 2017

European

on Health Systems and Policies a partnership hosted by WHO b .

The Country Health Profile series Contents The State of Health in the EU profiles provide a concise and 1 • HIGHLIGHTS 1 policy-relevant overview of health and health systems in the EU 2 • HEALTH IN MALTA 2 Member States, emphasising the particular characteristics and 3 • RISK FACTORS 6 challenges in each country. They are designed to support the efforts of Member States in their evidence-based policy making. 4 • THE HEALTH SYSTEM 7 5 • PERFORMANCE OF THE HEALTH SYSTEM 9 The Country Health Profiles are the joint work of the OECD and 5.1 Effectiveness 9 the European Observatory on Health Systems and Policies, in 5.2 Accessibility 11 cooperation with the European Commission. The team is grateful for the valuable comments and suggestions provided by Member 5.3 Resilience 12 States and the Health Systems and Policy Monitor network. 6 • KEY FINDINGS 16

Data and information sources The data and information in these Country Health Profiles are The calculated EU averages are weighted averages of the based mainly on national official statistics provided to Eurostat 28 Member States unless otherwise noted. and the OECD, which were validated in June 2017 to ensure the highest standards of data comparability. The sources and To download the Excel spreadsheet matching all the methods underlying these data are available in the Eurostat tables and graphs in this profile, just type the following Database and the OECD health database. Some additional data StatLinks into your Internet browser: also come from the Institute for Health Metrics and Evaluation http://dx.doi.org/10.1787/888933593703 (IHME), the European Centre for Disease Prevention and Control (ECDC), the Health Behaviour in School-Aged Children (HBSC) surveys and the World Health Organization (WHO), as well as other national sources.

Demographic and socioeconomic context in Malta, 2015

Malta EU

Demographic factors Population size (thousands) 432 509 394 Share of population over age 65 (%) 18.5 18.9 Fertility rate¹ 1.5 1.6

Socioeconomic factors GDP per capita (EUR PPP2) 26 800 28 900 Relative poverty rate3 (%) 8.5 10.8 Unemployment rate (%) 5.4 9.4

1. Number of children born per woman aged 15–49. 2. Purchasing power parity (PPP) is defined as the rate of currency conversion that equalises the purchasing power of different currencies by eliminating the differences in price levels between countries. 3. Percentage of persons living with less than 50% of median equivalised disposable income.

Source: Eurostat Database.

Disclaimer: The opinions expressed and arguments employed herein are solely those of the authors any territory, to the delimitation of international frontiers and boundaries and to the name of any and do not necessarily reflect the official views of the OECD or of its member countries, or of the territory, city or area. European Observatory on Health Systems and Policies or any of its Partners. The views expressed Additional disclaimers for WHO are visible at http://www.who.int/bulletin/disclaimer/en/ herein can in no way be taken to reflect the official opinion of the . This document, as well as any data and map included herein, are without prejudice to the status of or sovereignty over

© OECD and World Health Organization (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies) STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – MALTA Highlights . 1

1 Highlights Malta

Life expectancy in Malta is high and the population spend on average 90% of their lifespan in good health, longer than in any other EU country. The health system provides universal coverage and access to a comprehensive set of services, but private out-of-pocket payments remain high. New public-private partnerships aimed at increasing capital investment and quality of care are changing the role of the Ministry of Health from a pure provider to that of provider and contractor of services. Health status

Life expectancy at birth, years MT EU Life expectancy at birth was 81.9 years in 2015, up from 78.4 years in 2000 and above 82 81.9 the EU average of 80.6 years. Life expectancy gains are mainly the result of a reduction 81 of premature deaths from cardiovascular diseases, though these remain the leading 80 80.6 cause of death for both men and women. 79 78.4

78 77.3 81.9 77 YEARS 2000 2015 Risk factors

% of adults in 2014 MT EU In 2014, 20% of adults in Malta smoked tobacco every day, which is slightly below the EU

Smoking average. Heavy alcohol use also remains below the EU average, but consumption per adult 20% has increased since 2000, reaching 8.5 litres in 2014. prevalence is the highest in the EU and represents a significant public health challenge, with a quarter of the adult Binge drinking 19% population and 30% of 15-year-olds overweight or obese. Overweight/ obese 25% Health system

Per capita spending (EUR PPP) MT EU Health spending has increased steadily since 2005. In 2015, Malta spent EUR 2 255 per €4 000 capita on , compared to the EU average of EUR 2 797. This equals 8.4% of €3 000 GDP, below the EU average of 9.9%. Malta is among the top six EU countries with the

€2 000 highest private spending on health, amounting to 31% of total health expenditure in 2015,

€1 000 the majority of which is paid out of pocket.

€0 2005 2007 2009 2011 2013 2015 Health system performance

Effectiveness Access Resilience Amenable mortality in Malta remains Access to health care in Malta is good, with Malta faces some fiscal close to the EU average, but has fallen low numbers reporting unmet needs for challenges from an rapidly over the past 15 years due to lower medical care and little variation between ageing population, mortality from cardiovascular diseases income groups. increased chronic care and some treatable cancers needs and controls linked

Amenable mortality per 100 000 population MT EU % reporting unmet medical needs, 2015 to Fiscal Responsibility legislation for Eurozone countries. A 2015 Health System 180 182 High income All Low income 175 Performance Assessment identified future 160 MT improvement avenues to respond to these

140 pressures. 126 EU 123 120 2005 2014 0% 3% 6%

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – MALTA 2 . Health in Malta

Malta 2 Health in Malta

The Maltese population enjoys high life than men. Life expectancy at the age of 65 has also increased by expectancy one fifth since 2000 to 20.3 years, higher than the EU average (19.7 years). However, there is at least a three-year gap in life expectancy Life expectancy at birth in Malta has increased markedly over between people with lower and higher education qualifications.1 the past decade, surpassing the average increase across all EU countries. It reached 81.9 years in 2015, the sixth highest among EU 1. Lower education levels refer to people with less than primary, primary or lower secondary education (ISCED levels 0–2) while higher education levels refer to people with countries (Figure 1), with women living on average 4.3 years longer tertiary education (ISCED levels 5–8).

Figure 1. Life expectancy in Malta has increased substantially over the last 15 years Malta Years 2015 2000 90 81.9years of age

85 EU Average 80.6 years of age 83.0 82.7 82.4 82.4 82.2 81.9 81.8 81.6 81.6 81.5 81.3 81.3 81.1 81.1 81.0 80.9 80.8 80.7 80.6

80 78.7 78.0 77.5 77.5 76.7 75.7 75.0 74.8 74.7 75 74.6

70

65

60 EU Italy Spain Latvia Malta France Cyprus Poland Ireland Greece Austria Croatia Finland Estonia Sweden Belgium Bulgaria Portugal Hungary Slovenia Romania Denmark Germany Lithuania Netherlands Luxembourg Czech Republic Slovak Republic United Kingdom Source: Eurostat Database.

The number of healthy life years is the The leading cause of death in Malta is highest in the EU cardiovascular diseases, with a quarter of Not only do Maltese men and women live longer, they also enjoy deaths occurring prematurely close to 90% of their lifespan in good health. In 2015, the number Increases in life expectancy are mainly the result of a decrease of healthy life years at birth was 72.6 years for men and 74.6 in deaths from cardiovascular diseases, although they remain 2 years for women, the highest rate in the EU for women, and the the leading cause of death for men and women (Figure 3). Death second highest rate for men (Figure 2). Similarly, Maltese men rates from ischaemic heart disease in Malta remain above the EU and women aged 65 and over can expect to live 13.4 years and average but have shown a relatively consistent downward trend. 14.0 years respectively of their remaining life free of disability, the More than a quarter of all deaths from ischaemic heart disease second highest among EU countries. Despite these good results, the were premature, occurring in people aged under 75. These are increase of risk factors such as obesity and alcohol consumption in potentially preventable through appropriate action within the health recent years (see Section 3) may well have a negative impact on care system and wider policies affecting population health (see healthy life expectancy in the future. Section 5.1).

2. ‘Healthy life years’ measures the number of years that people can expect to live free of disability at different ages.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – MALTA Health in Malta . 3

Figure 2. enjoy the longest lifespan spent in good health among all EU countries Malta

Women Healthy Life Years (HLY) Men 74.6 Malta 72.6 73.8 Sweden 74 67.9 Ireland 66.6 67.5 Germany 65.3 65 Bulgaria 61.5 64.6 France 62.6 64.1 Spain 63.9 64.1 Greece 63.9 64 Belgium 64.4 63.7 Czech Republic 62.4 63.4 Cyprus 63.1 63.3 EU 62.6 63.3 United Kingdom 63.7 63.2 Poland 60.1 62.7 Italy 62.6 60.6 Luxembourg 63.7 60.1 Hungary 58.2 59.4 Romania 59 58.8 Lithuania 54.1 58.1 Austria 57.9 57.7 Slovenia 58.5 57.6 Denmark 60.4 57.2 Netherlands 61.1 56.8 Croatia 55.3 56.3 Finland 59.4 56.2 Estonia 53.8 55.1 Slovakia 54.8 55 Portugal 58.2 54.1 Latvia 51.8 80 70 60 50 40 30 20 10 0 Years 0 10 20 30 40 50 60 70 80

Source: Eurostat Database.

Mortality from treatable cancers and The burden of infectious diseases is low, but respiratory diseases have declined incidence of HIV and TB are rising substantially Infectious diseases have not been seen as a pressing health concern Overall, cancers account for 27% of all deaths in Malta. There in Malta and reported cases of major infectious diseases including has been a substantial reduction in breast cancer mortality since HIV and TB remain low. However, since 2006 rates of newly reported the early 2000s (Figure 4), bringing death rates down from the HIV diagnoses have more than doubled, and in 2015 Malta recorded highest in the EU to closer to the EU average. Further remarkable the third highest rate of newly reported HIV cases in the EU/EEA improvements in survival have been demonstrated for malignant (ECDC, 2016). This increase is largely attributable to outbreaks melanoma, testicular, thyroid and prostate cancers. However, among the men who have sex with men (MSM) community. Migrants outcomes have remained unchanged for some cancers, such as represent a further at risk group with foreign-born cases accounting those of the pancreas, stomach and brain, and specific types for more than half of newly reported HIV cases in 2015. of acute leukaemias in adults. Deaths from lung cancer have also remained fairly stable and are among the lowest in the Similar upward trends were observed for (TB) EU. Of other major causes of death, mortality from respiratory notifications between 2010–2014, although new notifications diseases also reduced steeply in the 2000s, converging to the EU declined in 2015 to 7.5 cases per 100,000 population, below the average. These trends partially reflect improvements in available EU/EEA average of 11.9. Approximately three-quarters of reported treatments and public health policies related to (see TB cases in 2015 were in individuals born outside of Malta, Section 5.1). far higher than the EU/EEA average of 30% of reported cases originating from outside the region (ECDC, 2017).

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – MALTA Malta has also risen substantially since 2000, reflecting rising obesity rates has alsorisensubstantiallysince2000, reflectingrisingobesityrates precise coding.Thedisabilityandmortality burdenfromdiabetes better diagnosisandlackofeffective treatments,aswell more DALYs upby nearly50%.Thisincreasereflectspopulationageing, other dementiashasincreasedsharplysince2000,withassociated The disabilityandmortalityburdenfromAlzheimer’s diseaseand (including lower backandneckpain)(IHME,2016). burden, wereischaemicheartdiseases,musculoskeletal disorders Malta in2015,takingintoaccountboththemortalityandmorbidity STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 –M diseases andriskfactors. OneDALY equals oneyearofhealthylife lost(IHME). 3. DALY isanindicatorusedtoestimatethetotalnumberofyearslostduespecific The leadingdeterminantsofdisabilityadjustedlife years disability adjustedlife years Chronic diseasesaccountfor alargeshareof Source: substantially rising are dementias and diabetes from deaths but stable, remain of death causes four top The 4. Figure dementia). Source: of form main (the disease Alzheimer’s with it include to chapter diseases’ system nervous the to added was Dementia chapter. ICD broad by presented are data Note: The cancer and diseases cardiovascular to due are Two 3. deaths of all Figure thirds 4 18 12 10 2000 ranking . 9 8 7 6 5 4 3 2 1 Health inMalta Eurostat Database. Eurostat 2014). to refer (data Database Eurostat 8% 9% 5% 2% 4% (Number ofdeaths:1630) Women 7% 24% 41% 2014 ranking ALTA 11 10 26 3 9 8 7 6 5 4 3 2 1 (DALYs) in Other causes External causes Digestive system Endocrine, metabolicsystem Nervous system(incl.dementia) Cancer Car Respiratory diseases diovascular diseases Skin diseases Breast cancer Pancreatic cancer Lower respiratorydiseases Colorectal cancer Pneumonia Alzheimer andotherdementia Diabetes Lung cancer Other heartdiseases Stroke Ischaemic heartdiseases level ofeducation. compared withfewer thanonetenthamongpeoplewiththehighest people withthelowest levelofeducationlivingwithhypertension, these chronicconditionsby educationlevel,withnearlyoneinthree lives withasthma.Wide inequalitiesexistintheprevalenceof hypertension, oneintwelveliveswithdiabetes,andseventeen (EHIS) indicatethatmorethanoneinfivepeopleMaltaliveswith Self-reported datafromthe2014EuropeanHealthInterviewSurvey underlying causeofdeaththanpreviousmanualcoding. recent yearsthathasahighertendencytochoosediabetesasthe (see Section socioeconomic disparities. older peoplewithlower educationallevels; however, thisalonedoesnotaccountfor all 4. Inequalitiesby educationmaypartiallybeattributedtothe higherproportionof 3) andachangetowards usingautomatedcodingin 4 5% 5% 10% 3% (Number ofdeaths:1696) 5% 5% Men 31% % ofalldeathsin2014 35% 12% 2% 2% 2% 2% 3% 3% 5% 6% 7% 9% 2% Health in Malta . 5

The majority of the population report being in Malta good health, but there are large disparities by 3 Risk factors income More than 70% of people in Malta report being in good health, which Malta’s obesity rate is a major public health is nearly on a par with the EU average (67%). However, there are concern large disparities across income groups, with 86% of people in the highest income group reporting to be in good health, compared to Behavioural risk factors contribute to a quarter of the total burden of only 55% of people in the lowest income group in 2015, the first time disease, with diet and smoking estimated to be jointly responsible for this rate has fallen below the EU28 average since 2010 (Figure 5). some 20% of all ill-health in 2015 (IHME, 2016). Figure 6 illustrates that Malta has the highest obesity rates in the EU for adults as Figure 5. There are large disparities in self-reported well as children. In 2014, one in four adults reported being obese health by income group (compared to the EU average of 16%), a steady increase from 23% Low income Total population High income in 2008. Rising obesity rates are partly attributable to a change in dietary patterns, with traditional Mediterranean diets being replaced Ireland by consumption of foods high in sugar, salt and saturated fats. Cyprus Sweden The overweight and obesity rate among 15-year-old children Netherlands has grown by 36% since 2001, and is now almost one in three Belgium (30%), more than one and half times the EU average. There are Greece¹ substantial differences in obesity rates between girls (26%) and Spain¹ boys (34%). The high rates in children foreshadow continuing high Denmark rates in the future as they enter adulthood. The government has Malta acknowledged the seriousness of the issue, launching a number of health promotion initiatives in recent years (see Section 5.1). Luxembourg Romania² Smoking rates continue to decline, but Austria Finland overall alcohol consumption is increasing United Kingdom Overall smoking rates have decreased steadily since 2000, with one France in five people aged over 15 currently being daily smokers. The daily EU smoking rate is still higher among men (26%) than women (16%) but Slovak Republic while the rate in men has declined, for women it has remained stable. Italy¹ Alcohol consumption in litres per capita has increased from 5.6 in Bulgaria 2000 to 8.5 in 2014, although this level has remained stable since Slovenia 2006 and remains below the EU average of 10. However, rates Germany of repeated drunkenness and binge drinking5, particularly among Czech Republic younger people, are a concern. More than 26% of 15-year-old Croatia boys and 28% of 15-year-old girls reported having been drunk at Poland least twice during their lives (in 2013–14). More generally, 19% of Hungary adults reported having had six or more alcoholic drinks on a single Estonia occasion at least once a month during the past 12 months, slightly Portugal below the EU average of 20%. This rate of binge drinking was two Latvia times greater among men than women (26% vs. 13%). Lithuania

20 30 40 50 60 70 80 90 100 % of adults reporting to be in good health

1. The shares for the total population and the low-income population are roughly the same. 2. The shares for the total population and the high-income population are roughly the same. 5. Binge drinking behaviour is defined as consuming six or more alcoholic beverages in a Source: Eurostat Database, based on EU-SILC (data refer to 2015). single occasion, at least once a month over the past year.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – MALTA Malta For example,inMaltaaquarterofpeoplewithlow education more commonamongpopulationswithlow socioeconomicstatus. Similar tomanyothercountries,behaviouralriskfactorstendbe according tosocioeconomicstatus Inequalities inriskbehaviourspersist Figure 6. Malta has the highest obesity rates for adults and children in the EU the in children and for adults rates obesity highest the has Malta 6. Figure STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 –M 6 . Risk factors Physical activity,15-year-olds Physical activity,adults Obesity, adults ALTA Overweight/obesity, 15-year-olds Smoking, 15-year-olds pollution andthequalityofphysicalenvironment. determinants ofhealth,suchaslivingandworkingconditions,air are long-standingandpointtowidersocioeconomicconditions obese comparedtoonlyonefifthinthehighest.Thesedifferences degree. Likewise, athirdofthoseinthelowest incomequintileare level aredailysmokers comparedto18%ofthosewithatertiary Health Statistics and HBSC survey in 2013–14. (Chart design: Laboratorio MeS). Laboratorio design: (Chart 2013–14. in survey HBSC and Statistics Health 2014), OECD around or in (EHIS Database Eurostat on based calculations OECD Source: Malta. for available not are adults among activity physical of measure acomprehensive on data Comparable areas. all in countries all in progress for room is there as area’ ‘target white the in is country No countries. EU other to compared performs country the better the centre the to is dot the closer Note: The Binge drinking,adults Smoking, adults Drunkenness, 15-year-olds The health system . 7

4 The health system Malta

Malta has a highly centralised National health expenditure (69%) is significantly below the EU average Health Service (79%) (see Figure 11 in Section 5.2), but has grown steadily from a historic low in 2010, benefiting in part from EU funding sources Malta has a tax-financed National Health Service (NHS) (Box 1). Malta is among the top third of countries with the highest characterised by predominantly public providers in the hospital private spending on health, nearly all of which is out of pocket. sector and a pluralism of providers in the primary care and ambulatory (or outpatient) care specialist sectors. Governance, Out-of-pocket spending is high due to regulation, provision and financing have until recently been fully centralised within the Ministry of Health, which owns and runs public significant private sector involvement in facilities. Past reform efforts have concentrated on defining the providing services regulatory and operational functions of the health system, improving The health system provides practically universal coverage for all management and enhancing delivery of services. In a new policy residents to a comprehensive basket of publicly provided health direction, Malta has entered into a 30-year public-private partnership services. Unlike many other European countries, there are no user agreement (from 2017) for capital investment and management charges or copayments for health services in Malta. However, responsibility for three hospitals with an international profit-making direct out-of-pocket payments are substantial and made primarily health care organisation (see Section 5.3). for pharmaceuticals and private general practitioners (GPs) and specialists, who are paid on a fee-for-service basis. The public share of health expenditure has increased in recent years The NHS is the key provider of health services, with the private sector acting as a complementary mechanism for health care Health expenditure per capita in Malta has increased by more than coverage and service delivery, particularly in primary care where the one third since 2005, reaching EUR 2 255 (adjusted for differences network of NHS public health centres operates alongside private in purchasing power) in 2015, which remains below the EU average GPs. Notably, private GPs account for two thirds of all primary (Figure 7). This equalled 8.4% of GDP, compared to the EU average care contacts, although the reasons for this are historical and of 9.9%. In terms of sources of funding, the public share of total cultural rather than a lack of GPs within the NHS. A large segment

Figure 7. Malta spends below the EU average on health care

EUR PPP % of GDP Per capita (le axis) Share of GDP (right axis) 6 000 12

5 000 10

4 000 8

3 000 6

2 000 4

1 000 2

0 0 EU Italy Spain Malta Latvia France Cyprus Poland Ireland Greece Austria Croatia Finland Estonia Sweden Belgium Bulgaria Portugal Hungary Slovenia Romania Denmark Germany Lithuania Netherlands Luxembourg Czech Republic Slovak Republic United Kingdom

Source: OECD Health Statistics, Eurostat Database, WHO Global Health Expenditure Database (data refer to 2015).

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – MALTA Malta own privateGPandsetappointments.Incontrast,publicclinics directly intheprivatesectorwherepatientscanfreelychoosetheir of thepopulationisaccustomedtoaccessingprimaryservices STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 –M average EU the to close Malta put now nurses and of physicians stock the increase to Policies 8. Figure 8 Source: hospital. in working those includes only it as underestimated is nurses of number the Greece, and Note: . measures to reduce health inequalities. health reduce to measures support to and professionals care health train to services, e-government develop and consolidate to allocated been have funds remaining The care. health into people vulnerable of integration support to and lifestyles healthy support to hospital, main the on pressure relieve to care health in for investment earmarked 19 million EUR with programme, 2014–2020 27.5 ESIF the EUR under million a further allocated been 2016). has Malta Commission, (European period programme the during expenditure health of total for 1.2% accounting investment, infrastructure care health for allocated were million 29 EUR totalling Funds Structural 2013, to 2007 From years. recent in sector Malta’s health in role asignificant played has (ESIF) Funds Investment and Structural European the from support Financial Practising nurses per 1 000 population, 2015 (or nearest year) 1. BOX The healthsystem In Portugal and Greece, data refer to all doctors licensed to practice, resulting in a large overestimation of the number of practising doctors (e.g. of around 30% in Portugal). In Austria Austria In Portugal). in 30% around of (e.g. doctors practising of number the of overestimation alarge in resulting practice, to licensed doctors all to refer data Greece, and Portugal In 10 15 20 Eurostat Database. Eurostat 0 5 1 THE HEALTH SECTOR SECTOR HEALTH THE IN ROLE IMPORTANT AN PLAYS FUNDING EU Nurses Low Doctors Low Nurses High Doctors Low 2 PL Practising doctorsper1000population, 2015(ornearestyear) RO UK IE SI HR 3 BE LU LV HU ALTA EU average:3.6 FR SK FI EE NL EU CY CZ DK ES IT Malta average, numbershaveincreasedby athirdsince2009. nurses (8.0per1 000population)isstillslightlybelow theEU within thenursingworkforce. Althoughthenumberofpractising average (Figure 8). Capacitybuildinghasalsobeenstrengthened 3.7 practisingdoctorsper1000population,slightlyabove the EU the numberofdoctorshasrisensteadilyover thedecade,reaching formal specialisationtrainingprogrammesinMalta.Consequently, agreement settingupaUKFoundationSchoolinMaltaandthrough has beeneffectively managedthroughamutual recognition Maltese doctorsoftencarryouttheirspecialisationtraining.This net outflow ofnewlygraduateddoctors,mainlytotheUKwhere Following itsEUaccessionin2004,Maltaexperiencedasevere rising numbersofdoctorsandnurses A focus oncapacitybuildinghasresultedin sector (seeSection 5.2). to avoidwaitinglistsfor certainoutpatientspecialitiesinthepublic is acombinationofculturalpreferences aswellamechanism choose toseekconsultationsdirectlyfromprivatespecialists.This undermines continuityofcare.Inambulatorycare,peoplemay many patientsfindhindersgooddoctor-patientrelationshipsand operate onawalk-inbasisandhavedifferent GPsonduty,which 4 BG DE SE LT PT 5 AT 6 EU average:8.4 Doctors High Doctors High EL Nurses High Nurses Low 7 Performance of the health system . 9

5 Performance of the health system Malta

5.1 EFFECTIVENESS significantly since the late 1990s, and five-year survival rates have improved to reach 87% (2010–14). Amenable mortality has halved since 2001 Mortality amenable to health care in Malta is now close to the EU Lower mortality and better survival from treatable cancers result average, although it lags behind neighbouring countries, particularly from combined efforts to introduce population-based screening for women6 (Figure 9). Looking at trends over time reveals programmes that allow for timely detection and effective treatment. impressive falls in amenable mortality over the past 15 years. This A national breast cancer screening programme was introduced in reflects the overall progress in providing better availability of, and 2009 following recommendations by the EU Council (IARC, 2017). access to, an increasing range of different services, medicines and Programme data show that the number of women taking up medical technologies. Examples of success include the remarkable screening has risen rapidly, reaching 61% in 2015. The swift uptake improvements in survival for some treatable cancers, such as of the programme has been encouraged by continuing awareness breast and testicular cancer. Breast cancer mortality has fallen campaigns. However, progress for other treatable cancers, such Figure 9. Big falls in amenable mortality rates mean that Malta is close to the EU average

Women Men Spain 64.4 France 92.1 France 64.9 Netherlands 96.4 Luxembourg 67.7 Luxembourg 107.9 Cyprus 69.3 Italy 108.2 Italy 74.1 Belgium 110.5 Finland 77.4 Denmark 113.7 Sweden 79.4 Spain 115.1 Netherlands 79.7 Cyprus 117.0 Belgium 80.7 Sweden 117.2 Austria 83.0 Ireland 133.0 Portugal 83.9 Austria 138.0 Denmark 85.4 United Kingdom 139.1 Greece 85.5 Germany 139.6 Germany 88.2 Malta 149.0 Slovenia 88.7 Portugal 152.1 Ireland 92.3 Finland 154.4 United Kingdom 94.4 EU 158.2 EU 97.5 Slovenia 160.3 Malta 98.7 Greece 168.2 Czech Republic 119.9 Poland 229.0 Poland 121.5 Czech Republic 242.5 Croatia 147.8 Croatia 278.2 Estonia 152.5 Slovak Republic 335.9 Slovak Republic 168.2 Estonia 350.7 Hungary 192.3 Hungary 361.3 Lithuania 196.3 Bulgaria 388.8 Bulgaria 207.1 Romania 415.0 Latvia 214.9 Lithuania 473.2 Romania 239.5 Latvia 501.2 0 100 200 300 400 500 0 200 400 600 Age-standardised rates per 100 000 population Age-standardised rates per 100 000 population

Source: Eurostat Database (data refer to 2014).

6. Amenable mortality is defined as premature deaths that could have been avoided through timely and effective health care.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – MALTA 10 . Performance of the health system

Malta as cervical and colorectal cancer, has lagged behind the EU BOX 2. A NATIONAL AMR ACTION PLAN IS UNDER overall. The 2011–2015 National Cancer Plan introduced national DEVELOPMENT organised screening programmes for cervical and colorectal cancer in order to begin addressing this issue more systematically, while Antimicrobial Resistance (AMR) is a major public health a new national cancer plan was released for consultation in early threat in Malta. Surveillance data show that in 2015 5.4% of 2017. Malta also offers Human Papilloma Virus tests as primary Klebsiella pneumoniae bloodstream infections were resistant screening for cervical cancer identification. to carbapenems, a major last-line class of antibiotics to treat bacterial infections, which is higher than the EU/EEA median Malta has low rates of important causes of (0.5%) and the fifth highest total in the EU/EEA (ECDC, 2017). preventable mortality Malta also reported the third highest proportion of Salmonella Typhimurium isolates resistant to ciprofloxacin in the EU/EEA Preventable mortality provides an important indicator of the (EFSA, 2017). The development of a National Action Plan on effectiveness of inter-sectoral public health policies. Malta is AMR was initiated by the Ministry of Health in 2016. among the countries with the lowest levels of important causes of preventable deaths in the EU, including lung cancer, transport injuries and, as an indicator for alcohol policies, liver disease. Improving the quality of acute care remains However, there is little room for complacency as lack of progress in further reducing mortality from chronic liver disease among Maltese critical to further reduce the avoidable men has led to an increase in the gender gap for preventable disease burden mortality from this cause in recent years. Much of the decrease in amenable mortality has been driven by a rapid fall in deaths from ischaemic heart disease, rates of which The urgency of this problem has been recognised by successive are now similar to the EU average, although they remain high governments. Alcohol is one of the four lifestyle-related factors compared to neighbouring countries. Falling smoking prevalence tackled by the 2010 Non-communicable Disease Strategy. and the introduction of local cardiac services from the mid-1990s Legislative measures to cut binge drinking through restrictions explain part of the steady decline in heart disease. Yet Malta records that reduce access to lower priced alcohol and its consumption in relatively high levels of deaths within 30 days of admission to specified areas were introduced in 2011. More recently, the first hospital for acute myocardial infarction, at 9.5 per 100 admissions national alcohol policy was issued for consultation in 2016. among those aged 45 years and older, compared with 7.4 in the EU and 5.5 in Italy (2013). Similarly, higher-than-EU-average Action has been taken to tackle smoking case-fatality rates were recorded for people hospitalised for stroke. rates and obesity Taken together, this may point to potentially systemic challenges in providing high quality treatment in the acute sector, although further Legislation has played a key role in combating smoking. Malta was investigation of the data is needed to better understand the causes one of the first countries to introduce a smoking ban in 2004 and for Malta’s lower performance on these indicators. has continually updated regulations on tobacco advertising and promotion. These efforts effectively contributed to a steady fall in smoking prevalence among adults, particularly among men. Better integration remains a priority Initiatives to enhance care coordination and integration have Malta has invested significant efforts to address the growing focused on , dementia and cancer as well as post- prevalence of overweight and obesity among children and adults, acute care arrangements. A well-established example is the shared with recent initiatives including the 2012 Healthy Weight for Life care diabetes programme, which involves GPs with specialist Strategy, the 2014 Food and Nutrition Action Plan and the 2016 training managing diabetes clinics in health centres, with support campaign. However, the impact of these from (hospital-based) diabetes specialists who organise clinics in initiatives has yet to be demonstrated and tackling obesity more the community. However, multiple efforts are needed to effectively effectively remains a key concern of the government. address the avoidable diabetes burden in Malta. The 2016 National Strategy for Diabetes exemplifies coordinated action along the patient journey to achieve this aim. It emphasises prevention and early diagnosis, expanded treatment options and the further development of integrated care and management of diabetes to prevent or delay complications.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – MALTA Performance of the health system . 11

5.2 ACCESSIBILITY Figure 10. The low level of self-reported unmet needs Malta also shows small variations across income groups Universal coverage in Malta contributes to High income Total population Low income low levels of unmet needs for health care Estonia The NHS can be accessed by all residents covered by Maltese social Greece security legislation. All necessary care is also available to other Romania groups living in Malta, such as foreign workers with valid work Latvia permits and irregular migrants. Malta has seen rapid increases in Poland Italy the numbers of irregular migrants, refugees and asylum seekers Bulgaria over the past decade. While there is no specific legislation with Finland respect to access to health care for irregular migrants, they have EU free access to health care through a system of administrative Portugal waivers on humanitarian grounds. As in other countries, this Lithuania vulnerable group may face barriers to using health services due Ireland to lack of information, fear, and language or cultural barriers. United Kingdom Third country nationals who are not covered under social security Hungary legislation have to pay for all health care services. Belgium Slovak Republic Population coverage in the public system is high, so in 2015 only Croatia 0.8% of the population reported feeling unable to obtain medical Cyprus care when needed because it was too expensive, too far to travel, Denmark or waiting lists were too long. This amounts to the sixth lowest France share in the EU (Figure 10). In addition, there is little variability in Sweden the reporting of unmet needs between the lowest income quintile Luxembourg (2.2%) and the highest (0.1%), suggesting fairly equitable access to Czech Republic services across income groups. Unmet needs for dental examination Malta are also very low, ranking fourth lowest among EU countries in Spain Germany 2015, despite some dental services not being covered for all Netherlands residents under the public health care system. Slovenia Austria Essential medicines are free of charge for 0 10 20 low income households % reporting unmet medical need, 2015 The publicly funded health system offers a comprehensive benefits Note: The data refer to unmet needs for a medical examination or treatment due to costs, distance to travel or waiting times. Caution is required in comparing the data across package. Entitlement to a few services, including elective dental countries as there are some variations in the survey instrument used. care, optical services and some formulary medicines, is means- Source: Eurostat Database, based on EU-SILC (data refer to 2015). tested. Therefore, people who fall within the defined low income bracket are entitled to free medicines from a list of essential medicines, including the introduction of Managed Entry Agreements medicines and to certain medical devices. Moreover, those who and the concept of clinical pathways and protocols for the suffer from chronic illnesses are also entitled to their disease- evaluation of new medicines. Furthermore, the President’s Malta specific medicines free of charge, without means-testing. Since Community Chest Fund (a philanthropic foundation) has extended 2008 these can be collected from any pharmacy, including those its role in financing drugs that are not yet included in the benefits in the private sector, resulting in improved access. In all other package. In addition, the second national cancer plan published cases, patients must purchase pharmaceuticals out of pocket, in 2017 outlines a government pledge to include more cancer except during hospitalisation and for the first three days following medications on the Government’s Formulary List in the coming discharge (MISSOC, 2016). years. Furthermore, the Government has pledged to increase access to medicines for rare diseases. Access to innovative medicines, however, remains a challenge. The government has adopted various savings measures in the medicines budget in order to spend more on expensive new

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – MALTA Malta Figure 11. Direct out-of-pocket payments are much higher in Malta than in most other EU countries EU other most in than Malta in higher much are payments out-of-pocket 11. Direct Figure STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 –M Source: specialists canprovide referrals tootherlevelsofcareinboththe specialists andhospitalcare,whereasprivatesectorGPs health clinicsactasfullgatekeepers, referring patientstopublic This ispartiallyduetoaweakgatekeeping system.GPsinpublic times havetraditionallybeenalong-standingchallengeinMalta. needs for medicalexamination duetowaitinglistsin2015, Although datashow thatonly0.1%ofrespondentsreportedunmet a numberofprivateinpatientandoutpatientcentres. oncology, rehabilitation,mentalhealthandolderpeople,aswell on theislandofGozo.Therearealsospecialisedhospitalsfor are twopublicacutehospitals,onelocatedonMaltaandtheother a majorissueinMaltaduetothesmallsizeofcountry. There Inability toaccesshealthservicesfor geographicalreasonsisnot reduced substantiallyinrecentyears Waiting listsfor inpatientcarehavebeen needs for medicalcareduetocost(2.4%in2015). this, thelowest incomegroupreportsverylow ratesofunmet income onhealththantheirhighercounterparts.Despite households inMaltagenerallyspendalargerproportionoftheir consumption, whichisthesecondhighestinEU.Low income of-pocket spendingaccountsfor 5%oftotalhousehold final (Figure 11). Thissharehasremainedstablesince2005.Out- totalled 29%,significantlyhigherthantheEUaverageof15% 2015, suchdirectpayments,asashareoftotalhealthexpenditure, and specialistcare,resultinginhighout-of-pocket expenditure.In choose toseekcareintheprivatesector,particularlyfor primary Although NHSservicesarefreeatthepointofuse,patientsoften seem toposeabarrieraccess High out-of-pocket expendituredoesnot 12 . Performance ofthehealthsystem OECD Health Statistics, Eurostat Database (data refer to 2015). to refer (data Database Eurostat Statistics, Health OECD 29% Malta 2% 69% ALTA Other Out-of-pocket health insurance Public/Compulsory insurance Voluntary health 5.3 RESILIENCE to reducingwaitingtimes. management ofoutpatientservicesisalsounderwaywithaview demand. Anongoingexercisetoimprove internalefficiencyinthe outpatient blocktoprovide increasedcapacitytocaterfor the other areasandtheGovernment iscommittedtobuildinganew to decreasewaitingtimesfor outpatienthospitalappointmentsin arthroscopic services,totheprivatesector. Moreremainstobedone outsourcing someprocedures,suchascataracttreatment,MRIand hospitals through,for example,introducingroutine Sundaylistsand reduced by increasingthenumberofproceduresperformed inpublic Waiting listsfor hospitalinterventionshavebeensuccessfully sector physicians. diagnostic andtherapeuticinterventionsby goingdirectlytoprivate able tobypass waitinglistsfor specialistambulatoryandelective equity ofaccess,giventhatpeoplewhocanafford todosoare back intothepublicsystem.Thereisalsoaproblemintermsof public andtheprivatesystems,thusreintroducingpatients using thehealthsystemandchangingpopulationriskbehaviours. include increased immigration from workers and pensioners, tourists chronic conditions.Otherfactorsstretchinghealthsystemcapacity costs ofcaringfor itsageingpopulationandassociatedincreasesin Malta facesimportantfiscalchallenges,inpartduetotheexpected health fiscal sustainabilityofpublicexpenditureon Economic reforms havestrengthenedthe environments, suddenshocksorcrises. 7. Resiliencerefers tohealthsystems’capacityadapteffectively tochanging 7 15% 5% 1% EU 79% Performance of the health system . 13

Projections from the EC 2015 Ageing Report (European Commission Malta is aiming to enhance its physical and Malta and Economic Policy Committee, 2015) suggest that Malta is eHealth infrastructure poised for an increase of 2.1% in health care expenditure as a share of GDP over the period 2013–60, the second largest increase Malta’s National Health System Strategy highlights the importance in the EU after Portugal. However, recent structural reforms and of modernising health centres by providing the latest technological investments in energy infrastructure have resulted in higher equipment. In this regard, the opening of the Mater Dei Hospital growth and a more buoyant labour market than initially projected. in 2007 and a new cancer hospital in late 2014 have enhanced The improved economic outlook for Malta has strengthened the capacity in clinical services. sustainability of public expenditure and is creating the necessary fiscal space to accommodate projected increases in health The National Strategy also gives particular attention to the use expenditure driven by the ageing process. Nevertheless, health of information technology and the creation of a Health Care budgets are still facing tight control in line with Fiscal Responsibility Information System. In particular, the rollout of the myHealth legislation introduced for Eurozone countries. Although current service since 2012 enables patients and doctors to access demographic trends do not pose any serious threat to the health electronic medical records through a nominated doctor of their sector’s fiscal sustainability, a strong commitment to securing choice and an e-ID card, thus strengthening continuity of care for adequate health budgets is required. patients. Moreover, investment plans have been drawn up for an integrated portfolio of eHealth systems that include the creation A new public-private partnership initiative of electronic patient records in primary health care, e-prescription aims to expand acute hospital capacity and services and patient registries. geriatric care Health Technology Assessment informs Limited availability of capital investment resources is one decision-making on the allocation of reason the government entered into a 30-year public–private resources partnership with a private contractor in 2016 for the refurbishment, development and management of three public hospitals in Malta Decisions on resource allocation are supported by a Health and the island of Gozo. Aside from transferring responsibility for Technology Assessment (HTA) system that has been in place since capital investment, the contract anticipates an expansion of acute 2010 to help deliver care that represents value for money. HTA is hospital capacity and geriatric care for Maltese residents as well used to inform decisions on whether to add new medicines to the as the creation of a niche medical tourism market, particularly for Government Formulary List, to set the relevant maximum reference one of the hospitals earmarked for rehabilitation services. The move price and to assess whether procedures should be included in the also entails a shift in stewardship arrangements: in contrast to its public benefit package. traditional ‘command and control’ role of direct management, the Ministry of Health is expected to exercise influence via its newly There is scope for increasing efficiency adopted role as the contractor of services. particularly through strengthening primary care The reform is the subject of an ongoing debate in Malta about the transparency of the ownership of these hospitals and equity in The cost-effectiveness of the health system can be intimated, access and coverage. The contracts were heavily redacted when albeit rather crudely, through relating amenable mortality rates presented in the public domain and have been referred to the to total per capita expenditure levels. On this measure, the result National Audit Office for scrutiny by the Ministry of Health. The for Malta is relatively low (Figure 12), implying that health care reform will need to be monitored carefully, not least to ascertain resources are generally used cost-effectively, but with the proviso whether it is contributing to the fiscal sustainability of the health that health behaviours as well as health system factors influence system and meeting other goals such as maintaining equitable the level of amenable mortality. Nevertheless, Malta has one of the access and improved quality of care. highest rates in the EU of hospital expenditure as a proportion of total expenditure in the public sector, which impacts on the health system’s efficiency.

Stronger primary care could contribute to improving the health system’s performance and efficiency in a number of ways. Firstly, the weak gatekeeper system leads to inappropriate referrals and

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – MALTA Malta 1 000 2 000 3 000 4 000 5 000 6 000 STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 –M Source: levels spending low given is relatively mortality Amenable 12. Figure Harbour area. facilities andtobuildaPrimaryCareRegionalHubintheSouthern investments havealsobeenmadetoupgradepublicprimarycare management clinicsandhealthylifestyle clinics.Infrastructure care hasbeenexpandedtoinclude,for example,chronicdisease specialists. Additionally,therangeofservicesprovided inprimary services thatcouldpreviouslyonlyberequestedby hospital in tothemyHealthsystemarenow abletomake referrals for primary care.Forexample,GPsandprivatefamilydoctorslinked Several initiativeshavealreadybeenadoptedtostrengthen towards preventingdeteriorationandtheneedfor hospitalcare. conditions betterwithinprimarycaresettingswouldcontribute where treatmentcostsaremuchhigher. Finally, managingchronic hospital emergencydepartmentsfor minorailmentsandconditions and communitycarewouldalsoresultinfewer self-referrals to could take placeinlesscostlysettings.Strengtheningpublicprimary contributes towastedresourcesintheform ofhospitalcarethat 14 Health expenditurepercapita,EURPPP . 0 Performance ofthehealthsystem OECD Health Statistics, Eurostat Database, WHO Global Health Expenditure Database (data refer to 2014). to refer (data Database Expenditure Health Global WHO Database, Eurostat Statistics, Health OECD 0 50 FR ES CY LU NL IT DK SE BE 100 FI PT AT DE IE EL Malta UK ALTA SI 150 PL CZ acute bedstomoreappropriatesettings. capacity thatpreventsthemovement ofdebilitatedpatientsfrom (Figure 13). Thisiscausedby pressuresonlong-termcarebedsand the averagelengthofstayinacutehospitalsover thepastdecade rates havebeenfurtherexacerbatedby asubstantialincreasein in 2015)comparedtotheEUaverage(76.6%).Bedoccupancy contributed toMalta’s relativelyhighbedoccupancy rate(81.7% decreased by around14%over theperiod2000–15.Thishas other EUcountries.Inacutecare,thenumberofhospitalbeds the EUaverage(5.2)butiscontrarytodecliningtrendinmany 4.7 per1 000populationin2014(Figure 13), whichisstillbelow number ofhospitalbedshasincreasedinrecentyears,reaching accurate levelsandtrends.With thiscaveatinmind,theoverall definitions ofbeds over theyears,makingitdifficulttoascertain hospital restructuring,changesindesignationsand In termsofbednumbers,largefluctuationsinthedatareflect the hospitalsector There isalsopotentialfor efficiency gainsin 200 HR EE SK 250 HU Amenable mortalityper100000population BG 300 LT RO LV 350 Performance of the health system . 15

Figure 13. The number of beds and the average length of stay are increasing Malta

Beds per 1 000 population Hospital beds Average length of stay in hospital ALOS (days)

10 10

9 9

8 8

7 7

6 6

5 5

4 4 2010 2011 2012 2013 2014 2015

Note: A break in time series occurred in 2011. Source: Eurostat Database.

Strategic tools have been formulated to In order to monitor the implementation of the Strategy, Malta strengthen governance developed its first Health Systems Performance Assessment (HSPA) in 2015, supported by the WHO (Grech et al., 2015). The overall The National Health Systems Strategy for 2014–2020 was adopted responsiveness of the health system emerged as being ‘good’. The in September 2014, the first since 1995. It sets out key objectives dimensions of financing, quality, access and health status emerged to address the challenges facing the health system, namely: as ‘fair’, while the health system scored poorly on the dimensions responding to the demands posed by demographic changes and of resources, efficiency and determinants of health, although it epidemiological trends; increasing equitable access, availability should be noted that the assessment set a high benchmark to and timeliness; improving quality of care; and ensuring fiscal achieve highly positive and positive scores. The stewardship domain sustainability. could not be assessed because of a lack of data for the selected indicators, signalling where information systems capabilities need The vision underlying the Strategy is that of a ‘whole of society’ to be improved to support monitoring and evaluation efforts. This approach to health improvement and building sustainable health first HSPA now serves as a baseline to gauge any improvements in systems grounded on healthy communities in line with the WHO domains of evaluation over time. European Health Policy – Health 2020. The Strategy focuses on strengthening prevention and primary care, making better use of technologies, harnessing existing resources and further developing health system governance to ensure the development of a sustainable health system that respects the fundamental principle of equitable access for all.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – MALTA Malta STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 –M l l l l 16

. centre. health primary of anew development the facilities and improve to investments infrastructure of services, range of the expansion an include care primary strengthen to initiatives Ongoing conditions. chronic with for patients of care management better ensuring and care hospital on pressure reducing from gains efficiency including users, its and system health Maltese the for benefits of anumber reap would care primary Strengthening budgets. health adequate securing to commitment astrong requires needs changing with cope to capacity system health improving Nevertheless, expenditure. health in increases projected accommodate to space fiscal necessary the creating currently are management fiscal prudent and reforms economic recent However, needs. care chronic rising commensurate with population ageing and growing diverse, increasingly an to due challenges fiscal faces important Malta challenge. major health public a represents and EU the in highest is the prevalence obesity particular, In future. the in lifehealthy expectancy on may impact well have and anegative countries EU other to compared of are concern factors risk some However, needs. low of levels unmet generally and status health good by life high expectancy, evidenced as progress, good registered has system health Maltese The create an equity issue. equity an create afford it could can who for those lists waiting by-pass to order in specialists private to access direct as especially apriority, remains hospitals public in appointments specialist for outpatient times waiting Reducing sector. private the from services some commissioning and capacity increasing including of measures, number a through diagnostics and interventions for surgical times waiting long tackled successfully has Malta Key findings 6 Keyfindings ALTA l l l

the introduction of managed entry agreements. agreements. entry of managed introduction the and medicines of new evaluation for the protocols and pathways of use clinical the include These medicines. new expensive on more spend to order in budget medicines the in measures savings various adopted has government the response, In challenge. budgetary important an remains medicines innovative expensive to Access prepared. is being strategy Adigital forof patients. care continuity and quality enhance will also but spending care health of efficiency term longer to will contribute only not registries, patient and e-prescriptions care, primary in records medical electronic as such Malta’s infrastructure, eHealth in of development stage next of the implementation The money and quality of care for the health system. health for of the care quality and money for value expected the derive and objectives policy their meet they that will ensure arrangements new of these evaluation and monitoring Careful of amatter urgency. as is needed change this underpin to framework governance legislative and Arobust facilities. government-operated through services care of provider health adirect being to opposed as of care, purchaser the role as a relatively new entails services Health’s of sector private commissioning of Ministry The of services. management and investment infrastructure hospital enhance to agreements, public-private partnership through arrangements stewardship system health new on embarked has Malta Health in Malta . c

Key sources Malta

Azzopardi-Muscat, N. et al. (2017), “Malta: Health System OECD/EU (2016), Health at a Glance: 2016 – State of Review”, Health Systems in Transition, Vol. 19(1), pp. 1–137. Health in the EU Cycle, OECD Publishing, Paris, http://dx.doi. org/10.1787/9789264265592-en.

References

ADEM (2017), “Panorama du marché de l’emploi”, Agence pour IGSS (2016), Rapport Général sur la Sécurité Sociale au Grand- le développement de l’emploi, http://www.adem.public.lu/fr/ Duché de Malta 2016, Inspection Générale de la Sécurité marche-emploi-Malta/panorama-marche-emploi/index.html, Sociale, Malta. accessed on 22/02/2017. IHME (2016), “Global Health Data Exchange”, Institute for Health CNS (2016), Rapport Annuel 2015, Caisse National de Santé, Metrics and Evaluation, available at Malta. http://ghdx.healthdata.org/gbd-results-tool.

European Centre for Disease Prevention and Control/WHO Kringos, D. et al. (2015), “Malta”, in D. Kringos et al. (eds.), Regional Office for Europe (2017) Tuberculosis surveillance Building Primary Care in a Changing Europe. Case Studies, and monitoring in Europe 2017. Surveillance Report. Observatory Studies Series 40, WHO Regional Office for Stockholm: ECDC. Europe, Copenhagen, pp. 163–170.

European Centre for Disease Prevention and Control/ WHO Kringos, D. et al. (2013), “Building Primary Care in a Changing Regional Office for Europe (2016) HIV/AIDS surveillance in Europe”, Observatory Studies Series 38, Vol. 1, WHO Regional Europe 2015. Surveillance Report. Stockholm: ECDC. Office for Europe, Copenhagen.

European Commission (2015), “Patients’ Rights in Cross-border Maier, C.B. et al. (2014), “Monitoring Health Professional Mobility Healthcare in the European Union”, Special Eurobarometer in Europe”, in J. Buchan et al. (eds.), Health Professional 425, Directorate General for Health and Consumers (SANCO). Mobility in a Changing Europe – New Dynamics, Mobile Individuals and Diverse Responses, World Health Organization European Commission (DG ECFIN) and Economic Policy (on behalf of the European Observatory on Health Systems Committee (AWG), “The 2015 Ageing Report – Economic and and Policies), Copenhagen, pp. 95-127. budgetary projections for the 28 EU Member States (2013– 2060)”, European Economy 3, Brussels, May.

Country abbreviations Austria AT Denmark DK Hungary HU Malta MT Slovenia SI Belgium BE Estonia EE Ireland IE Netherlands NL Spain ES Bulgaria BG Finland FI Italy IT Poland PL Sweden SE Croatia HR France FR Latvia LV Portugal PT United Kingdom UK Cyprus CY Germany DE Lithuania LT Romania RO Czech Republic CZ Greece EL Luxembourg LU Slovak Republic SK

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – MALTA State of Health in the EU Country Health Profile 2017

The Country Health Profiles are an important step in the Each Country Health Profile provides a short synthesis of: European Commission’s two-year State of Health in the EU l  health status cycle and are the result of joint work between the Organisation l  the determinants of health, focussing on behavioural risk for Economic Co-operation and Development (OECD) and the factors European Observatory on Health Systems and Policies. This l  the organisation of the health system series was co-ordinated by the Commission and produced with l  the effectiveness, accessibility and resilience of the health the financial assistance of the European Union. system

The concise, policy relevant profiles are based on a transparent, This is the first series of biennial country profiles, published in consistent methodology, using both quantitative and qualitative November 2017. The Commission is complementing the key data, yet flexibly adapted to the context of each EU Member findings of these country profiles with a Companion Report. State. The aim is to create a means for mutual learning and voluntary exchange that supports the efforts of Member States For more information see: ec.europa.eu/health/state in their evidence-based policy making.

Please cite this publication as:

OECD/European Observatory on Health Systems and Policies (2017), Malta: Country Health Profile 2017, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels. http://dx.doi.org/10.1787/9789264283497-en

ISBN 9789264283497 (PDF)

Series: State of Health in the EU ISSN 25227041 (online)

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