A National Health Systems Strategy for

2014-2020

Securing our health systemS for future generations First published in June 2014

© Parliamentary Secretariat for Health Ministry for Energy and Health

Parliamentary Secretariat for Health Ministry for Energy and Health Palazzo , 15 Merchants’ Street, VLT 2000, Malta Tel: (356) 2122 4071 Email: [email protected]

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The Department for Policy in Health within the Parliamentary Secretariat for Health, Ministry for Energy and Health would like to thank all those persons and organizations who have contributed to and participated in the consultation process and the drawing up of this report.

Editorship: Department for Policy in Health within the Parliamentary Secretariat for Health, Ministry for Energy and Health Foreword Working towards safe and sustainable health systems for all

The appreciates how close health Better use of current technologies, such as the is to the Maltese citizen’s heart and has therefore Internet and mobile networks, is another key to a declared health and healthcare a top priority in its work more sustainable health sector. E-health and m-health plan. Testament to this is the continued investment services would complement and support the excellent in the health sector in order to bring health closer to care provided by our health providers by delivering the people. The challenges that threaten the success information where and when it is needed, empowering of such investment are multiple. One main challenge the citizen to take control of one’s own health and is the burden on health brought about by one of the enabling the policy maker to channel investment where successes of the health service itself – a higher life it is most required. expectancy. This, coupled with the ever-increasing Harnessing our existing resources and engaging demand for new technologies and treatments, modern in governance is pivotal to attaining the maximum lifestyle challenges, together with the requirement and potential of one’s investment. The Government believes expectation to deliver a high quality service nonetheless, wholeheartedly in the quality of the main resource in led to the need to have an overarching national health this sector – our health workforce. Empowering our systems strategy. Such a vision is pivotal to bring health providers to attain their maximum potential excellence in health within reach of all those who require through providing access to further training and it, and ensuring that this can be sustained for many medical research will help the country to achieve the years to come. excellence envisioned for Maltese healthcare. Indeed, The National Health Systems Strategy is building on for such a highly capable resource to deliver excellence, the solid foundations of our present health systems it also requires the right infrastructure. This applies to ensure that an accessible and fair health service is particularly to the development of the role of primary maintained and continuously improved. The Government health services in Malta. We also believe in the role of is committed to keep providing free quality healthcare to specialised centres of excellence which will continue to all. This is coupled with our aim to maximize well-being put Malta on the regional health map. in our population, throughout one’s life course. After all, To this end it is with great pleasure that I am presenting a country‘s economic growth and development depends Malta’s National Health Systems Strategy for the period entirely on the health of its population.

2014 to 2020. The Government is committing itself to Foreword Therefore, the way towards attaining sustainability in lead its implementation and support its execution as healthcare is not in restricting access to health for our part of its resolve to address long-term challenges. By population, but through prevention, efficiency and better sharing this vision, the Government is inviting all other use of the resources available to us in order to deliver entities in the public sector and also the private sector 3 the maximum benefit for our continued investment in to engage and partake in its implementation. I am also the health sector. inviting you, as a Maltese citizen, to own this vision and make it yours so we can move together in the same Strengthening prevention is key to the maintenance of direction - towards achieving a sustainable health care a healthy population – not only primary prevention to service that delivers high quality care to all. prevent the onset of disease, but also helping those with disease to keep it in check and minimize the effect that disease may have on their daily activity. To attain this we need to foster an environment that supports people in leading a healthier lifestyle. This requires the involvement of our whole society.

We strongly believe that efficiency and sustainability can Hon. Mr. Chris Fearne be gained by investing further in delivering health closer MD, FRCS Ed, MP to our communities. Our dedicated family doctors are Parliamentary Secretary for Health already well placed to achieve this vision and this sector needs to be empowered with more services within primary health care, including specialist care and advice.

Table of contents

Foreword 3 Table of contents 5 Table of contents and boxes 8 Table of figures and tables 9 Glossary / Acronyms 10 Executive summary 11

Chapter 1 Background 15

1.1 The need for a National Health Systems Strategy (NHSS) 15 1.2 The population of the Maltese islands 16 1.3 The organisation of the Maltese health systems 21

Chapter 2 Methodology and consultative process 25

2.1 Project team 25 2.2 Timeline and activities 25 2.3 Consultation 27

Chapter 3 Alignment with WHO and EU health strategies 29

3.1 Introduction 29 3.2 Achieving positive health outcomes 29 of contents Table 3.3 Life course approach 30 3.4 Health in all policies 30 3.5 Dynamic health systems 31 5 3.6 Health, economic prosperity and growth 31 3.7 Monitoring health systems 32 3.8 Reforms needed to improve the sustainability of health systems 33 3.9 Conclusion 33

Chapter 4 Setting the goals for the Health SystemS Strategy 35

4.1 Introduction 35 4.2 The strategic overarching role of information and communication technology (ICT) 37 4.3 The rationale behind the four overall objectives and seven strategic directions 38

Overall objective 1 Health and well-being throughout life 38 Strategic direction 1a The right care at the right place at the right time 38

Strategic direction 1b Engagement and empowerment to promote health 39

Overall objective 2 Ensuring equity within dynamic health systems and ensure sustained progress 39

Strategic direction 2a Making best use of available resources 40

Overall objective 3 A joint effort to ensure continuity of care 40

Strategic direction 3a Establishing standards within a patient-centered approach 41

Strategic direction 3b Safe, high quality and efficient services 41

Overall objective 4 Working towards sustainable health systems 42

Strategic direction 4a Integrated planning as an essential part of sustainable health systems 42

Strategic direction 4b Improving leadership: participatory governance for health 43

Chapter 5 key baseline indicators illustrating the overall objectives of the national health systemS strategy 45

5.1 Introduction 45 5.2 Increased demand and challenges due to demographic changes, epidemiological trends, ageing and vulnerable groups: 46 A. Demography 46 B. Lifestyle indicators 48 i. 49 ii. High blood pressure and blood cholesterol levels 50 iii. 50 iv. Alcohol consumption 51 v. Diet 52 C. Incidence of disease 53 of contents Table i. Communicable diseases: special focus on Koch (TB) and Hepatitis B 53 ii. 53 iii. Hospital discharges for ischaemic heart disease, 6 cerebrovascular and respiratory system diseases 53 iv. Malignant neoplasms (cancer) 54 v. 54 vi. Utilisation of Long-term Care 56 5.3 Access, availability and timeliness of services, medicines and medical technologies 56 A. Avoidable admissions 56 B. Medical technology 57 C. Secondary Care 57 D. Unmet need 58 E. Community services for the elderly 58 F. Oncology services 58 5.4 Quality of care including patient safety, continuity and consistency of care, implementation of protocols and/or international guidelines 59 A. Trained health care workforce 59 B. National Cancer Screening Programmes 60 C. Vaccination 60 D. Hospital Stay and Readmissions 61 5.5 The need for a long term vision for the sustainability of our health systems 61 5.6 Health policies & strategies 63

CHAPTER 6 PEOPLE AT THE HEART OF THE HEALTH SYSTEMS (THE PEOPLE-CENTRED APPROACH) 65

6.1 Introduction 65 6.2 The evolving concept of people-centered approach 67 6.3 The values, principles and characteristics of a people-centered health systems approach 68 A. Individuals, families and communities 68 B. Health practitioners 68 C. Health care organizations 69 D. Health Authorities 69

CHAPTER 7 IMPLEMENTATION OF A PEOPLE-CENTRED NATIONAL HEALTH SYSTEMS: OBJECTIVES, DIRECTIONS AND MEASURES 71

7.1 overall objective 1 Health and well-being throughout life 71

Strategic direction 1a The right care at the right place at the right time 71 Individuals, families and communities 71 of contents Table Health practitioners 73 Health care organisations 73 Health authorities 74 7 Strategic direction 1b Engagement and empowerment to promote health 75 Individuals, families and communities 76 Health practitioners 76 Health care organisations 77 Health authorities 78

7.2 Overall objective 2 Ensuring equity within dynamic health system 79

Strategic direction 2a Making best use of available resources and ensure sustained progress 79 Individuals, families and communities 79 Health practitioners 80 Health care organisations 81 Health authorities 83 7.3 OVERALL OBJECTIVE 3 A joint effort to ensure continuity of care 84 Actions to develop the strategic overarching role of information and communication technology in health (health ict) 84

Strategic direction 3a Establishing standards within a patient-centered approach 85 Individuals, families and communities 86 Health practitioners 86 Health care organisations 87 Health authorities 88

Strategic direction 3b Safe, high quality and efficient services 88 Individuals, families and communities 88 Health practitioners 89 Health care organisations 89 Health authorities 90

7.4 Overall objective 4 Working towards sustainable health system 91

Strategic direction 4a Integrated planning as an essential part of sustainable health systems 91 Individuals, families and communities 91 Health practitioners 91 Health care organisations 92 Health authorities 92

Strategic direction 4b Improving leadership and participatory governance for health 93 Individuals, families and communities 94 Health practitioners 94 Health care organisations 95 Health authorities 95

and boxes of contents Table Chapter 8 governance of the national health systems strategy 97

8 8.1 Introduction 97 8.2 The budgetary framework 98 8.3 Implementing the national health systems strategy 98 8.4 Measuring health systems performance 99 8.5 Steering the implementation of the National Health Systems Strategy 100

References 101 Table of Boxes

Box 1: The pillars of the NHSS 14

Box 2: The pressures facing health systems 15

Box 3: Documents used in the compilation of the strategic directions and actions of the NHSS 26

Box 4 The pillars of the NHSS 36 T able of figures

Figure 1: Population pyramids for population of the Maltese islands in 2010, 2025 and 2060 46

Figure 2: Average acute length of stay in Malta, EU and other European countries – 1990-2010 61

Table of tables

Table 1: Trends in population/demographic indicators, selected years 17

Table 2: Mortality and health indicators, selected years 18

Table 3: Health indicators in Malta over the period 1984-2010 20

Table 4: Maternal, child and adolescent health indicators, selected years 21

Table 5: Sources of expenditure as a percentage of the total expenditure on health 2012 22

Table 6: Leading causes of death by number, rate and percent, 2012 47

Table 7: Demographic and epidemiological data for Malta, EU average and EU-15 for 2010 48

Table 8: Percentage of children reported to be overweight or obese according to BMI, ages 11-15 49

Table 9: Number of classes and number of participants at weight management and aerobics classes organized by the health promotion 50

Table 10: Changes in percentages of normal blood pressure and desirable blood cholesterol levels in Maltese adults from 1984 and 2010 50

Table 11: Number of classes and number of participants at smoking cessation clinics organized by the Health Promotion Unit 51

Table 12: Data on smoking and alcohol consumption 51

Table 13: Comparison of fruit and vegetable consumption in Maltese and European adults 52

Table 14: Percentage of children reporting daily fruit and vegetable consumption by gender in Malta, 2002-2010 52

Table 15: Comparison of hospital discharges for ischaemic heart disease, cerebrovascular diseases and respiratory system diseases in 2009 in Malta and EU average and EU-15 countries 53

Table 16: Age-standardised incidence rates per 100,000 and age-standardised mortality rates for the Maltese population for 2010 and EU-25 countries for 2006 for all cancers and other selected cancers (using European Standard Population) 55 Table of figures and tables of figures Table Table 17: Avoidable admissions: asthma and chronic obstructive pulmonary disease (COPD) in Malta and EU countries – 2009 56

Table 18: Avoidable admissions: diabetes with and without complications – 2009 57

Table 19: Items of functioning diagnostic imaging technologies in Malta 9 and selected countries per 100,000 population for the year 2011 57

Table 20: Self-reported unmet needs for medical examination for reasons of barriers of access in Malta and countries: Reason being too expensive or too far to travel or waiting list 58

Table 21: Number of students per 100,000 population who graduated in the health care professions in Malta and the EU countries for the year 2010 59

Table 22: Vaccination coverage in children in 2012 60

Table 23: Trends in health expenditure in Malta, 1995 to 2010 62

Table 24: Different players within the 4 key policy and action domains in the people-centred health systems approach 66 Glossary / Acronyms

A&E Accident and Emergency AD Alternattiva Demokratika / Democratic Alternative party AGS Annual Growth Survey AIDS Acquired Immunodeficiency Virus BMI Body Mass Index CSR Country Specific Recommendations CT Computed Tomography DHIR Directorate for Health Information and Research DTP Diphtheria, Tetanus and Polio ECHI European Common Health Indicators EHES European Health Examination Survey EHIS European Health Interview Survey ESP European Standard Population ESPAD European School Survey Project on Alcohol and other Drugs EU European Union EUROCARE European Cancer Registry FOBT Faecal Occult Blood Test GDP Gross Domestic Product HiAP Health in All Policies HiB Haemophilus Influenza type B HIV Human Immunodeficiency Virus HLY Healthy Life Years HPDP Health Promotion and Disease Prevention HSPA Health Systems Performance Assessment ICCC Innovative Care for Chronic Conditions ICT Information and Communication Technologies IHI Institute of Health Care Improvement IOM Institute of Medicine LTC Long-term Care

Glossary / Acronyms Glossary MEH Ministry for Energy and Health MFIN Ministry for Finance MMR Measles, Mumps and Rubella MONICA Multinational MONItoring of trends and determinants 10 in study MRI Magnetic Resonance Imaging NHA National Health Accounts NHIS National Health Interview Survey NHSS National Health Systems Strategy NOIS National Obstetrics Information System NRP National Reform Programmes NSO National Statistics Office OECD Organisation for Economic Co-operation and Development PET Positron Emission Tomography PL Partit Laburista / PN Partit Nazzjonalista / Nationalist Party SDR Standardised Death Rate SILC Survey Statistics on Income and Living Conditions WHO World Health Organization Executive Summary

A number of reasons contributed towards the need for the Ministry for Energy and Health to issue an overarching National Health Systems Strategy. The last umbrella national health strategy: Health Vision 2000 was issued in 1995. The national health systems in Malta are continuously trying to manage a fast changing environment and several challenges to safeguard and ensure universal access, high quality of care and sustainable services. In response to these challenges, a growing number of strategies specific to selected sectors have been published or are being developed. There is a pressing need to develop a horizontal overarching strategy to ensure consistency and a coherent and all encompassing response and action to the challenges that are being encountered.

The Maltese population is ageing with a steady decrease in the percentage of persons under 15 years and an increase in the number of persons 65 years and over. Life expectancy has steadily increased over the past 20 years so that in 2011, life expectancy at birth was 83.1 years for women and 78.8 years for men.

The National Health Systems Strategy (NHSS) needs to ensure universal access to high quality health services and economic sustainability, within the available budgetary resources, and incorporate strategies aimed at:

• improving and increasing available services;

• promoting and streamlining interactions between different services to ensure continuity of care;

• improving and increasing services to citizens who are not patients including prevention and screening, and health promotion services aimed at the population in general and/or specific

to identified vulnerable groups. Summary Executive

The NHSS revolves around a set of four overall objectives and seven strategic directions. The objectives encompass the strategic policies identified from an in-depth review of the accumulated thematic strategies and policy documents issued over the past twenty years 11 and the deliberations of the task force that was created in 2012 to draft this national strategy. The objectives are also guided and informed by international literature and in particular by the ‘Health 2020: a European policy framework supporting action across government and society for health and well-being’ adopted by the World Health Organisation (WHO), European Region issued in 2012 and the ‘EU Health Strategy - Together for Health: A Strategic Approach for the EU 2008- 2013’ adopted by the European Council in 2007. The overall objectives and the corresponding strategic directions are presented in Box 1 at the end of this summary.

The strategic actions and tactics identified for the implementation of each strategic direction are presented in a structure informed by a people-centred approach because this strategy is encompassing the broader view of an overarching health system rather than just concentrating only on the more familiar and visible health care systems. A people-centred approach is distinct from the more commonly portrayed patient-centred approach because it recognises that before people become patients they need to be informed and empowered in promoting and protecting their own health. The people-centred approach recognises four major groups of stakeholders. All these groups work for and are concerned with the success of the health systems. These four groups or policy and action domains include the following:

INDIVIDUALS, families and communities

HEALTH practitioners

HEALTH care organisations

HEALTH authorities

To achieve any real transformation in any part of the health systems these domains must mutually reinforce each other and leadership within and across all domains is recognized as the ultimate enabler for change. Accordingly, the actions presented for each of the strategic directions have been classified according to each of the above four major groups of stakeholders.

The main thrusts of the actions aimed at engaging individuals, families and communities include educating members of the public to acquire personal skills which allow control over their health and engagement with health care systems such as skills to improve communication, allow involvement in decision-making, and increase capacity for self- monitoring and self-care. Engagement will also be sought by formally recognising and increasing support to informal carers in the community, through initiatives to increase the general public’s confidence and trust in primary health care and by strengthening

Executive Summary Executive the importance of the roles of the local government, voluntary organisations and patient groups in the provision of health services.

Actions targeting health practitioners will focus on ensuring that they uphold respect 12 for patients, their needs and decisions at the clinical level and value communities and their needs at the population health level through the reinforcement of professional skills and competence in communicating, empathy and responsiveness, health promotion and disease prevention. Practices that promote access to professional development and debriefing opportunities, adherence to evidence-based guidelines and protocols, commitment to quality, safe and ethical care, teamwork and collaboration across disciplines, providing coordinated care and ensuring continuity of care and involvement in health care governance and policy decision-making are included as actions for this group of stakeholders.

Health care organizations are involved with actions needing to guarantee access to all people needing health care and to realise their commitment to quality, safe and ethical patient care. Actions also include the continuation of initiatives to provide safe and welcoming physical environment supportive of different lifestyles, and the needs of patients and their family for protection of their privacy and dignity. The acknowledgement of the importance of all levels of staff in the delivery of health care is upheld in this strategy. Other actions include the development of more effective avenues to address grievances and complaints and the organization of services that provide convenience and continuity of care to patients.

Finally, health authorities will be mandated to ensure that primary health care will continue to evolve as the foundation for better health, to strengthen financing arrangements that ensure the sustainability of the health system, to continue investment in health professional education that promotes multi-disciplinary teamwork, good communication skills, and a stronger orientation towards prevention. Actions are also included to increase the national capability to develop and disseminate standards and protocols, to augment uptake and use of Information and Communication technologies (ICT) to assist in the dissemination of information on patients, ensure continuity of care and facilitate decision-making both by the patients and the health practitioners and to foster more transparency and accountability in the operations of the national health systems. Executive Summary Executive

13 Box 1 | The pillars of the NHSS

IMPROVED HEALTH, INNOVATING THE WAY FORWARD: OVERALL OBJECTIVES AND STRATEGIC DIRECTIONS OF THE NHSS

Overall Objective 1 Respond to increasing demand and challenges posed by the demographic changes and epidemiological trends focusing on the whole course of life, children, the elderly and vulnerable groups.

Strategic Direction 1A Prolonging stay in the community and responding to increasing demands for higher dependency care.

Strategic Direction 1B Strengthening the prevention and promotion of health focusing on behavioural changes and lifestyle choices including protection, screening and early diagnosis and control of disease progression.

Overall Objective 2 Increase equitable access, availability and timeliness of health and social services, medicines and health technologies.

Strategic Direction 2A Improving management and efficiency of services through research and innovation, prioritisation, monitoring, public private partnership, and other service provision models.

Overall Objective 3 Improve quality of care by ensuring consistency of care delivered by competent health workers supported by robust information systems.

Strategic Direction 3A Setting and enforcing quality standards including licensing and accreditation and development and systematic application of case management protocols. Executive Summary Executive Strategic Direction 3B Facilitating continuity of care through co-ordination and integration within and between service provider teams and by improving communication and sharing of information. 14 Overall Objective 4 Ensure the sustainability of the Maltese Health Systems.

Strategic Direction 4A Designing, developing and evaluating sustainable policies for human resources, financing mechanisms, entitlement criteria for care and organization of care delivery.

Strategic Direction 4B Improving governance and empowering future leadership for health and well- being to influence national decisions through whole-of-government and whole- of-society approaches. Chapter 1 Background

1.1 The need for a National Health Systems Strategy (NHSS)

The vision of the Ministry responsible for Health is to actively promote a society that fosters an environment that is conducive to persons attaining their maximum potential for health and well- being. In order to attain these goals, the Ministry has embarked on an exercise to formulate a National Health Systems Strategy for the period 2014 to 2020 (NHSS). The aim of this strategy is to provide every individual with the opportunity to lead a healthy and active life, and to benefit from equitable access to sustainable quality health care.

Health is being increasingly seen as a resource to one’s daily living. It is being decreasingly seen as an end in itself but more as a means for an active and productive life. The cliché’ “there’s no wealth without health” is progressively more and continuously being reiterated in public health and political fora and applies not only at an individual level but also at a community, national and European level.

The first ever National Strategy for Health, the “Health Vision 2000”, was published in 1995. This valuable document has given a good description of the nation’s health status at the time, while describing a reform for the health services and setting targets for intervention within particular key areas. Whilst this has been an important and timely work which influenced health policy over these last 18 years, the time has come to renew our vision and devise a new strategy for health, based on today’s disease epidemiology and health needs.

The Maltese health system in line with several health systems worldwide have to cope with a fast changing environment. These include epidemiologically changes such as in terms Chapter 1 Chapter of changing age structures and the emergence of new threats, political transformations in terms of changing perceptions about the role of the state and its relation with the private sector and civil society, a general public and patients that are becoming more and more knowledgeable and discerning, and technical revolutions with increasingly sophisticated and 15 expensive treatment options on offer.

Box 2 | The pressures facing health systems 1

The drive for greater efficiency, productivity and cost control;

The growing demand for healthcare as a result of aging populations and improvements in medical technology and pharmaceuticals;

The need to devise effective and sustainable responses to increasing consumer demands for greater patient choice, better and faster access to services and the growing number of patients’ rights movements;

The need to manage long-term or chronic diseases such as diabetes, heart disease and obesity, precipitated by increasing longevity, lifestyle and environmental changes.

Source: Goodwin, N. (2005) Leadership in Healthcare: A European Perspective. In response to these challenges, a growing number of strategies specific to selected sectors have been published or are being developed. However, there is an acute need to develop a horizontal overarching strategy to ensure consistency and a coherent response and action to the challenges that are being encountered in a holistic fashion. The NHSS has been created to provide the role of the umbrella strategy for all the sectoral health policies and strategies that have been launched since 2000 and that will be completed over the next few years.

Furthermore, the need to design, produce and implement a new NHSS is the requirement for such a strategy vis-à-vis national endeavours to succeed in the application for initiatives to acquire future EU and international funding. This funding is required for the further improvement and development of the Maltese health system. This requires that a national strategy for health is in place that ensures access to quality health services and economic sustainability and that within the available budgetary resources for health care provides for and contains:

• coordinated measures to improve access to quality health services;

• measures to stimulate efficiency in the health sector, including through deployment of effective innovative technologies, service delivery models and infrastructure;

• an effective and sustainable monitoring and review system*.

1.2 The population of the Maltese Islands

The three main islands, Malta, Gozo and Comino, form an archipelago in the Mediterranean Sea that has the highest average population density in (1325 persons per km2). The total population was 417,432 in 2011. (61)

Population growth has slowed from 1.0% per year in 1990 to 0.5% per year in 2010. (3) While the crude death rate has been relatively stable over the past 20 years (7. 9 per 1,000 persons in 2011) there has been a decline in the fertility rate from 2 births per

Chapter 1 Chapter woman in 1991 to 1.4 in 2012. The crude birth rate was 10.1 births per 1,000 in 2012. (5)

The Maltese population is ageing with a decrease in the percentage of persons under 15 years which in 2011 accounts for 14.8% of the population, and an increase 16 in the number of persons 65 years and over which now account for 16.3% of the population; the percentage of persons aged 80 years and over is also steadily increasing, standing at 3.6% of the total population in 2011. The old-age dependency ratio of 23.7% is lower than the EU average (26.8%) as at 2011. (61)

As of 2011, 91.6% of residents were born in Malta; most others were born in the United Kingdom, Australia or Canada. (61) In 2010 there was an estimated net immigration of 2,247 persons, mainly from other EU member states, as well as returning Maltese nationals. While there is little reliable data from 2005-2009, authorities reported an average of 1,911 irregular immigrants per year by boat, though only 47 were reported

* Proposal for a Regulation of the European Parliament and of the Council laying down common provisions on the European Regional Development Fund, the European Social Fund, the Cohesion Fund, the European Agricultural Fund for Rural by Development and the European Maritime and Fisheries Fund covered by the Common Strategic Framework and laying down general provisions on the European Regional Development Fund, the European Social Fund and the Cohesion Fund and repealing Regulation (EC) No 1083/2006 table 1 | Trends in population/demographic indicators, selected years

1980 1990 1995 2000 2005 2010

Total Populationa 325,721b 361,908 378,404 391,415 405,006 417,617

Population, female 51.40c 50.83 50.59 50.52 50.41 50.29 (% of total)a

Population aged 0-14 24.21 23.47 21.76 20.06 17.39 15.42 (% of total)d

Population aged 65 and above 8.27 10.42 11.03 12.22 13.37 15.16 (% of total)d

Population aged 80 and above 0.90 1.96 2.17 2.44 2.95 3.44 (% of total)e

Population growth 1.00 1.00 0.70 0.50 0.60 0.50 (average annual growth rate)c

Population density 993.75 1106.56 1158.75 1205.65 1260.97 1299.97 (people per sq km)d

Fertility rate, total 2.00c 2.00 1.80 1.70 1.37 1.40 (births per woman)d

Birth rate, crude 17.62 15.16 12.44 11.30 9.56 9.66 per 1,000 people)d

Death rate, crude 10.38 7.65 7.30 7.71 7.76 7.24 (per 1,000 people)d Chapter 1 Chapter Age dependency ratio (population 0-14 & 65+; 48.20c 51.16 50.33 47.22 44.05 44.47 population 15-64 years)e

Distribution of population 89.79 90.38 90.95 92.37 93.65 94.67 17 (rural/urban)d

Proportion of single-person n/a n/a 14.80f n/a 18.90f 18.80g households

School enrollment tertiary 2.54 10.72 21.54 19.85 30.72 36.48 (% gross)c

Sources: a Demographic Review 2010, NSO b Demographic Review 1990, NSO c World Development Indicators, World Bank d European Health for All database, WHO e (Demographic Review 2010, 2005, 2000, 1990, NSO) f Census 2005, NSO g Statistics on Income and Living Conditions 2010, NSO in 2010. (2) Most are from Africa, with a small proportion from Asia. From a health perspective, there are concerns that these immigrants may suffer from infectious diseases which are not endemic in Malta.

Life expectancy has steadily increased over the past 20 years and compares well with the EU average. In 2011, life expectancy at birth was 78.8 years for men and 83.1 years for women. (5)

Standardised death rates (SDR) for circulatory diseases have decreased over time from 426 per 100,000 population in 1990 to 231 per 100,000 in 2011, but are still higher than those of the EU-15†. The probability of dying in the younger age groups (15-60) has been decreasing steadily with a wide gap between males and females, (3) partly attributable to ischaemic heart disease and external causes of death such as traffic accidents and suicides. The overall age-standardised death rate has also been steadily declining and was 660 per 100,000 in males and 442 per 100,000 in females in 2011. (5)

table 2 | Mortality and Health Indicators, selected years (3)

1980 1990 1995 2000 2005 2010

Total 70.4 76.2 77.3 78.2 79.4 81.5 (5)

Male 67.9 73.8 75.0 76.0 77.2 79.3 (YEARS) birth

at L ife e x pectancy Female 72.9 78.4 79.6 80.3 81.4 83.6

Adult 144.0 122.2 112.6 103.7 95.5 87.3 male*

Adult Chapter 1 Chapter 80.3 64.7 58.1 52.2 46.9 42.7 ) population

or male adult Female* rate M ortality ( per 1000 female

Source: European Health for All Database, WHO and World Development Indicators, World Bank. Note: *probability of a 15 year old dying before age 60, if subject to current age-specific mortality rates between 18 these ages.

Deaths due to diseases of the circulatory system are the leading causes of death, accounting for 47% of all deaths in 2012. The SDR from ischaemic heart desease heart desease seems to have changed from a downward trend to an upward trend in 2010 and 2012 it is considerably higher than the SDR for the EU-15. As for diabetes mellitus, there was a decrease in the age-standardised mortality rate between 2009 and 2012 which may be atributed to changes in coding practices whereby diabetes is considered as a contributory condition to the cause of death rather than being the underlying cause of death. (6)

† EU-15 area countries are those who formed part of the EU prior to April 30th, 2004: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden and United Kingdom Neoplasms are the next most common cause of death and accounted for 27% of all deaths in 2012. While the overall number of deaths has been increasing over time, standardised mortality rates reveal a downward trend that compares well with the EU-15 and all EU countries. The average age at death due to neoplasms is 71.3 years, 8.4 years younger than for circulatory diseases. Lung cancer, followed by colorectal cancer and pancreatic cancers are the leading causes of death from neoplasms in males. Breast cancer, followed by colorectal cancer and lung cancer, are the leading causes of death from neoplasms in females. (6) For most cancers there have been improvements in survival rates, however for some types of cancer, survival rates in Malta are lower than in the EUROCARE (European Cancer Registry) pool§. (7) (8)

Low mortality rates from infectious diseases can be attributed to widespread availability of antibiotics. The most common infections reported in 2012 were food borne illness, Chlamydia infection, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), latent syphilis and . (9) The free syringe distribution programme for intravenous drug abusers which started in Malta in the late 1980s has resulted in low rates of HIV infection. A free childhood immunization programme for all children also has resulted in lower morbidity and mortality from vaccine preventable infectious diseases.

Despite health gains, many risk factors associated with non-communicable diseases in Malta are on the rise. Chronic conditions associated with obesity, unhealthy lifestyles and ageing (such as dementia) are major challenges facing the population as a whole. According to body mass index (BMI) data, the percentage of the male population that is obese has increased from 22.1 percent in 1984 to 24.3 percent in 2008. Data comparing Malta to other EU member states in 2008 found that the proportion of males who are obese in Malta is the highest in the EU while the proportion of females who are obese is third highest. (17) The proportion of children who are obese or overweight is also one of the highest when compared to children in 41 other countries. (11) Along these lines, according to the European Health Interview Survey (EHIS), 8% of the population aged 15 years and over reported having diabetes in 2008. (17)

Even though males still smoke more than females, the gap is shrinking. According to the latest European School Survey Project on Alcohol and other Drugs (ESPAD) carried out in 2011, 22% of Maltese students aged between 15-16 years participating in the study had smoked during the 30 days before the survey. The study also found that 68% of those surveyed had consumed alcohol during previous 30 days compared to 57% which is the ESPAD average. (14) Chapter 1 Chapter The average infant mortality rate for the period 2010 to 2012 was 5.1 deaths per 1000 live births* which is above with EU average of 4 deaths per 1000 live births in 2011. (5) When considering the infant mortality rate for Malta, the fact that abortion (terminations of pregnancy) is illegal must be considered. According to the National Obstetrics Information System (NOIS), the 19 highest number of deliveries by maternal age group during 2012 was in the 30-34 group. (15) The percentage of births to teenage mothers has increased since the 1990s. (5)

The maternal mortality ratio is defined as the number of maternal deaths per 100,000 live births. Over the past ten years from 2004-2012, two maternal deaths were registered. There were no maternal deaths in 8 out of the 10 years in this time period. The maternal mortality ratio over this time period was 4.97 per 100,000 live births (49). This rate compares well with the average overall European maternal mortality ratio quoted in the European Perinatal Health Report 2010 (http://www.europeristat.com )that stands at 6.2/100,000 live births. *

§ The EUROCARE study is a cancer register based study on survival and care of cancer patients. The EUROCARE pool includes 23 European countries: Austria, Belgium, Czech Republic, Denmark, Finland, France Germany, Iceland, Ireland, Italy, Malta, Norway, Poland, Portugal, Slovenia, Spain, Sweden, Switzerland, the Netherlands, United Kingdom (UK) England, UK Northern Ireland, UK Scotland, UK Wales § The average infant mortality rate was calculated using data on the number of deaths and the number of live births over the period 2010 to 2012 using the official figures from the National Mortality Register. table 3 | Health Indicators in Malta over the period 1984-2010

Age MONICA NHIS EHIS Pilot group 1984 2002 2008 EHES 2010

M F M F M F M F (%) (%) (%) (%) (%) (%) (%) (%)

BMI: 18.5-24.9 kg/m2 25-64 32.4 33.3 29.4 48.0 25.4 48.1 23.1 45.2 (normal)a

BMI: 25.0-29.9 kg/m2 25-64 45.5 31.4 42.2 30.6 46.9 31.0 47.2 28.9 (overweight)

BMI: ≥30.0 kg/m2 25-64 22.1 35.3 28.5 21.4 27.7 21.0 29.6 28.0 (obese)

Elevated blood ≥18 N/A N/A 7.1 7.4 9.6 7.8 9.0 10.7 glucoseb years

Normal blood 25-64 51.5 52.9 82.5 83.9 78.4 80.3 66.9 68.7 pressurec

Elevated blood 25-64 N/A N/A 17.5 16.1 21.6 19.7 N/A N/A pressured

Stage 1e 25-64 32.7 30.9 N/A N/A N/A N/A 30.8 16.3 hypertension

Stage 2f 25-64 15.8 16.3 N/A N/A N/A N/A 2.3 15.1 hypertension

Total serum cholesterol 25-64 22.9 21.0 N/A N/A N/A N/A 31.3 44.0 ≤5.00 mmol/L Chapter 1 Chapter Borderline high 25-64 30.1 29.9 N/A N/A N/A N/A 39.1 41.4 >5.00-6.18 mmol/L

High >6.18 20 25-64 47.0 49.1 N/A N/A N/A N/A 29.7 14.7 mmol/L

Sources: Multinational MONItoring of trends and determinants in CArdiovascular disease (MONICA) project European Health Interview Survey (EHIS), 2008, National Health Interview Survey (NHIS), 2002, European Health Examination Survey (EHES) Pilot study, 2010,

Notes: a measured height and weight for MONICA and EHES; self-reported for NHIS 2002 and EHIS 2008 b measured in mmol/L for EHES; self-reported (lifetime prevalence of diabetes) for EHIS 2008 c measured (systolic <140mmhg and diastolic<90mmhg) for MONICA and EHES; self-reported (no lifetime prevalence of hypertension) for NHIS 2002 and EHIS 2008 d self-reported (lifetime prevalence of hypertension) for NHIS 2002 and EHIS 2008 e measured systolic ≥140-159 mmHg or diastolic ≥90-99 mmHg f measured systolic ≥160 mmHg or diastolic ≥100 mmHg table 4 | Maternal, child and adolescent health indicators, selected years (5)

1980 1990 1995 2000 2005 2010

% of all live births to mothers 3.11a 2.68 3.08 5.57 5.94 6.37 <20 years of age

Termination of pregnancy 0.00 0.00 0.00 0.00 0.00 0.00 (abortion) rate*

Peri-natal mortality rate 17.90b 10.93 9.94 4.60 3.12 6.22

Neonatal mortality rate 11.96 6.71 7.37 5.27 4.41 4.48 (deaths per 1000 live births)

Post-natal mortality rate 3.57 2.79 1.52 0.69 1.56 1.00 (deaths per 1000 live births)

Infant mortality rate 15.53 9.50 8.89 5.96 5.96 5.48 (deaths per 1000 live births)

Probability of dying before 18.14 10.99 10.21 6.80 6.70 6.46 age 5 years per 1000 live births

Syphilis incidence rate N/A N/A N/A 0.00 4.96 5.77 (per 100,000 population)

Gonococcal infection incidence rate N/A N/A N/A 0.78 5.70 11.3c (per 100,000 population)

Source: European Health for All database, WHO Notes: a 1984; b 1985; c 2008; * Induced termination of pregnancy (abortion) is illegal in Malta Chapter 1 Chapter

1.3 The organisation of the Maltese Health SystemS 21

In Malta and Gozo, health services are provided mainly by the state and the private sector. The Catholic Church and voluntary organisations also contribute especially in the provision of long-term and community care services. The public health care system provides a comprehensive basket of health services to all persons residing in Malta who are covered by the Maltese social security legislation and also provides for all necessary care to special groups such as irregular immigrants or foreign workers who have valid work permits. Only a few services including elective dental services, optical services and coverage of certain formulary medicines are means-tested. The private sector provides coverage for those that wish to access private services.

The national health systems are organised and governed by two main actors:

1. The Ministry for Energy and Health (MEH). This Ministry is responsible for the financing and the provision of health care for all the population 2. The Ministry for Finance (MFIN). This Ministry collects taxes and allocates them to various sectors including public health care.

Other actors include other Government Ministries, the Foundation of Medical Services, Government Commissions, Agencies, Boards and Committees, Professional Regulatory Bodies and professional groups, Local Councils, private and voluntary sectors, the church and the general public.

The total expenditure on health as a percentage of gross domestic product (GDP) was 9.1% in 2012 according to National Health Accounts (NHA) data. About two-thirds of the total health care expenditure is financed by the state while private spending accounts for the remaining one-third. (16)

table 5 | Percentage of the total expenditure on health by source of revenue (2008) (17)

Sources of expenditure on health % of total expenditure on health

General government expenditure 65.6

Out-of-pocket payments 32.3

Voluntary health insurance 2.2

Source: National Health Accounts, WHO

The statutory health care system is funded by tax revenues. All forms of taxation feed into the Consolidated Fund, from which all public budgets (including the budget for health) are drawn on an annual basis. The National Insurance Fund scheme is one form Chapter 1 Chapter of taxation contributing to the Consolidated Fund. This scheme is accumulated as follows: employers and employees each contribute 10% of wages, self-occupied persons contribute 15% of their income, and the government contributes 50% of the combined 22 contributions of the previously mentioned groups. The main private sources of health care financing are out-of-pocket payments. A much smaller proportion is through voluntary health insurance schemes. Out-of- pocket payments account for a significant part of private health care expenditures (93.8% in 2012). (16)

There are five public hospitals, of which two are acute general hospitals and three are specialised hospitals. The acute public general hospital in Malta is also a university teaching hospital. As of end 2012 Malta also has three private hospitals. One of the problems Malta has been facing is a high bed occupancy rate in acute hospitals (81.5% in 2010) which is above the EU average (76.3% in 2010). Moreover, the number of beds per 100,000 in acute hospitals is below the EU average, and has decreased by around 29% over the past decade. However, the average length of stay in acute hospitals has remained lower than most other Mediterranean countries since the 1990s and is below the EU average. (5) The number of human resources per capita, namely specialist physicians, dentists, and nurses are below the EU average except for the number of paediatricians, pharmacists, and midwives. On a positive note, the quantity of health workers is gradually increasing. (5) This has been effectively managed through a mutual recognition agreement with the United Kingdom General Medical Council (as most medical school graduates undergo specialist training in the United Kingdom) and through the setup of formal specialisation training programmes in Malta.

The state health service and private general practitioners provide primary health care in Malta. Dental care is provided by both public and private providers. Secondary and tertiary care are provided through the public and privately owned general hospitals. Most of the secondary care provided in the public sector in the main hospital is free of charge. The bulk of day and emergency care is also provided by the main acute general hospital. In the public sector, medicines listed on the Government Formulary List are given free of charge to entitled patients. In the private sector, patients must pay the full cost of pharmaceuticals.

Rehabilitation services are offered by the public rehabilitation hospital free of charge to patients referred following inpatient admission at the public hospitals, or who are referred from the community by a general practitioner. Long-term care for the elderly is provided by the State, the church and the private sector, and also through partnerships between the State and the private sector. Community-based services are being promoted and aimed in particular to help keep the elderly population active and residing in their homes for as long as possible.

In recent years, substantial improvements have been made in the areas of palliative care and mental health care. In 2011, a specialist 10-bedded palliative care ward was opened in the oncology hospital. Major efforts have been dedicated towards increasing the provision of more community-based mental health services. Lastly, to deal with the influx of irregular immigrants the Migrant Health Unit was set up in 2008 to deal with the specific needs of this population.

Since the publication of Health Vision 2000, the national health of the population of Malta has shown significant progress. This is manifested by consistent increases in life expectancy at birth and healthy life expectancy and decreases in general mortality. The Maltese health system has achieved and maintained high levels in terms of equity, universal coverage and comprehensiveness. For example, according to EU Statistics on Income and Living Conditions (SILC) data, self-reported unmet need due to financial constraints in 2011 was markedly low in comparison to other European countries. (18) Indeed, socio-economic inequalities are more evident among health determinants, such as obesity and health literacy, rather than for access 1 Chapter to health care services.

For these reasons, the NHSS and the sectoral health strategies are all geared to focus on reducing premature deaths, addressing risk factors, decreasing morbidity, promoting 23 healthy lifestyles, improving access to health services for all, particularly for disadvantaged groups and improving quality of life.

C M Chapter 2 2.2 2.1 Project onsultative P ** A system isasetofinter-related elementsconnected to eachother, directly orindirectly. Inhealthcare, there are many ethodology and Timeline • Provides abasisfor re-design • Fosters integration between components andpeople • Allows for abroad scope solution • Avoids excessive attention to asinglecomponent part • Helpsidentifyimportantrelationships andprovides proper perspective • Facilitates theidentification ofmajorcomponents offuture change • Aidsinidentifyingandunderstanding thebigpicture brings away ofunderstanding complexity. Specifically, a systems approach: such interconnections across primary, secondary andspecialist services aswell aswithsocialcare. Systems thinking adopting thedefinitionofahealth system implemented by the World HealthOrganisation: the NHSS. The remit ofstrategy willencompass theoverall healthsystem. For thisreason, thestrategy is The initialdiscussions alsoresulted indecisions beingtaken onthemainapproaches andstructures for government entities.Box 3lists thedocumentsthat were includedinthisexercise. published orlaunchedfor consultation duringthepast 2-3 years by otherMinistries and the project team alsoevaluated anumberofpoliciesandstrategies that have beendrafted, strategy inthemid-1990s by theMinistry and entities responsible for health.Furthermore, launched and/or implemented since thepublication ofthelast overarching national health in alonglist ofpolicy, strategy, andactionplansdocumentsthat have beenprepared, This was initiated by analysing andaggregating thecontent, direction andactionsincluded developed concurrently, thefirst task to beundertaken was to give priority to theNHSS. drawn up. Itwas recognised that althoughideally boththeNHSS andtheHSPA would be During thepreliminary discussions aroad mapfor thedevelopment oftheNHSS was Performance Assessment (HSPA). Work ontheHSPA commenced inearly2014. will bealsoassisting theDepartmentofHealthonwork associated withtheHealthSystems expert from thisDirectorate metthree timeswiththeproject team. This technical assistance of HealthSystems HealthoftheWHOEurope. andPublic From September to November, an Since September 2012, thisgroup benefitted from technical assistance from theDirectorate World HealthOrganisation. started inJune2012. Aworking group was setupandworked inclosecollaboration withthe Work onthepreparation for thedrafting ofaNational HealthSystems Strategy (NHSS) team and activities

rocess

25 Chapter 2 26 Chapter 2 Note: a PL=Partit Laburista; PN=Partit Nazzjonalista ;AD=Alternattiva Demokratika National DementiaStrategy (2015-2023) National Sexual HealthStrategy T A National Strategy for Malta Prevention, C C T Healthy Weight for Life disease inMalta A Strategy for thePrevention andC Health V Name ofdocument National Policy ontheRightsofPersons with Disability Environment Protection andR MEP MEP Food andNutritionPolicy And services withspecialattention to children withspecialneeds Strategy oncommunity paediatric healthcare health care services for personswitheating disorders. A Health Systems inT Pre-budget documents2011, 2012 and2013 National Strategic R and inclusion(Malta) National R Proposal for areform ofthePrimaryHealthCare National Planfor Rare Diseases Inclusion Green Paper: A Framework for Poverty R C ‘T Strategic Plan for theEnvironment andDevelopment Electoral programmes for Health(PL,PNAD) National Strategy for A he National Cancer Plan2011-2015 he National Sexual HealthPolicy for theMaltese Islands ommunicable diseasestrategy ommission for ChildPolicy andStrategy dvisory report onthedevelopment ofspecialised Box 3| he V A C A C oice oftheChildinare’: R ision 2000–ANational HealthPolicy onsultation document-T onsultation document-For anEfficientPlanning System eports onstrategies for socialprotection and actions oftheNHSS Document ontrol andManagementofT eference Framework –Malta2007-2013 (NSRF) ransition, Malta ctive A s uedinthec geing: Malta2014-2020 esource Management ction Plan2014-2020 owards HighStandards for eport by theNational ontrol ofNon-communicable ompilation ofthes eduction andfor Social uberculosis: trategic directions (launched for consultation (launched for consultation (launched for consultation (launched for consultation (launched for consultation) (launched for consultation) 2011 /2012 / 2013 Publication date 2006 2009 2008 Draft Draft Draft 2010 2010 2014 2014 2014 2014 2014 2014 2014 2014 2014 2014 2013 2013 2012 2012 1995 2011 2011 ) ) ) ) 2.3 C onsultation These 2exercises formed thebasisfor theNHSS that isbeingpresented inthisdocument. objectives withtheirrespective strategic directions canbeviewed inBox 4(section 4.2). been furtherelaborated withtwo oronestrategic directions. The wholelist oftheseoverall directions for thisNHSS. Inall,four overall objectives were set.These objectives have each completed anexercise ofextracting anddeveloping theoverall objectives andstrategic and includedinthefinalisation ofthis exercise. Duringthisprocess, theproject team also feedback from thePermanent Secretary andChiefMedicalOfficer were also considered actions from theavailable documentsmentionedinBox 3.Information, direction and By theendof2012, theproject team completed theexercise ofdissecting andaggregating for theNHSS canbeviewed insection4.2. sector orfacility. Amore detaileddescriptionandjustification for theuseofthisframework the general community longbefore they become patients andenter aclinicalhealthcare interventions, inparticularprevention andhealthpromotion, anditaimsto reach peoplein approach recognises andaddresses bothhealthcare interactions aswell aspublichealth activities includedinthisstrategy was basedon thepeople-centred approach. This The structure that was adopted for thepresentation andcategorisation ofthestrategic improving andincreasing services to citizens whoare notpatients includingprevention• and promoting andstreamlining interactions between different services to ensure• continuity ofcare; improving andincreasing theservices whichapatient receives inthehealthcare• facilities; incorporate strategies aimedat: This strategy willtake abroad view through ahealthsystems perspective** (20)andwill promote, restore ormaintainhealth A healthsystem consists of allorganizations, peopleandactionswhoseprimaryintent isto process leading to thedevelopment ofthefinal version oftheNHSS. reports onthediscussions at theseworkshops were includedandevaluated intherevision organisations andhealthauthorities.The seminarhosted sixworkshops and thedetailed families, localgovernment, voluntary organisations, healthcare professionals, healthcare approach were adequately represented. These includedrepresentatives ofpatients andtheir Invitations alsoensured that allthegroups ofthe four domains ofthepeople-centred content oftheNHSS. identified asimportantpartners to help continue to inform thefurther development in the with theimplementation ofspecificobjectives andactionsofthe strategy and/or were range ofstakeholders. The stakeholders includedpersonsandentitiesthat willbetasked The launchevent was organized asaseminarthat includedinvited participantsfrom awide consultation process were organised. consultation process continued untiltheendofMarch 2014. Three events andanelectronic The first version oftheNHSS was launched for consultation onthe21st February 2014. The specific to identifiedvulnerable groups. screening, andhealthpromotion services aimedeitherat thepopulation ingeneral and/or

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27 Chapter 2 28 Chapter 2 version oftheNHSS. meticulously analysed and anumberoftheseproposals were assimilated inthefinal detailed inputfrom different entitiesandassociations. Allthis feedback was By theendofconsultation periodtheMinistry received 34documentswith and interested personsandentitieswere invited to sendtheirfeedback. during thetimeframe oftheconsultation process. Participants at thelaunchevents The NHSS documentwas alsomadeaccessible electronically ontheMinistry’s website electronic feedback. process through participation intheevents orthrough thedelivery ofwritten or and to invite civilsocietyandthegeneral publicto contribute to theconsultation also organised. The mainaimoftheseevents was to widelypublicisetheNHSS Two events aimedat theinvolvement andengagementofawideraudience were and EU and A Chapter 3 3.2 3.1 I A ntroduction lignment with W with lignment positivechieving health outcomes public healthinEngland’issued by theUKDepartmentofHealth in2012 have alsobeen identifiedasprioritiesinthe‘Healthy Lives, Healthy People: Our strategy for increasing healthy anddisability-free life expectancy andreducing healthinequalities.These systems. There isaconsensus inbothstrategies ontheneedfor healthsystems to focus on budgetary constraints andresource limitations isconstantly increasing the strain onhealth right balance between providing universal access to high-qualityhealthservices andrespecting or goalscommon to boththeEUandWHO strategy documents.The pressure to strike the Universality, access to goodqualityhealthcare, equityandsustainability are theshared values objectives andprioritiesidentified for addressing theseproblems. strategies, thechallengethat healthsystems have to face andmanageaswell asthestrategic A closelookat bothdocumentsreveals anumberofsimilaritiesin thevalues underpinningthe 2. 1. Two majorinternational strategic frameworks for healthinourcontext are: by theWHOandEU. Systems Strategy (NHSS) isguidedandinformed by relevant policy documentspublished create apositive response andto achieve gaininhealthandwell-being. The National Health of thewholepopulation orsocietyandthewholeofGovernment working inunisonto Evidence andexperience from around theworld clearlyshow that ittakes theinvolvement population andreducing inequalitiesinhealth,rather thanfocused onprocess targets’. wholesystemthe ‘the willberefocused around achieving positive healthoutcomes for the Malta inSeptember 2012. for healthand well-being’, adopted by theWHOEurope 62ndRegional Committee heldin ‘Health 2020: aEuropean policy framework supportingactionacross government andsociety This documentwas adopted by theEuropean Commission inOctober 2007; The EUHealthStrategy -‘Together for Health:AStrategic Approach for theEU 2008-2013’. health strategies health HO (21) whichstated that

29 Chapter 3 30 Chapter 3 3.4 3.3 L

H ife 4. 3. 2. 1. development justifies citizens’ involvement through: and behaviour onhealthy development andageing. and employment entitiesandorganisations to reinforce knowledge andskills,attitude intervention andpartnershipsbetween healthinstitutions andfor example education or leaving school,starting afamily andgoinginto retirement present opportunitiesfor Europe (2002) active role intheirindividualhealthandtheof communities. The WHO 2013. Ireland -Aframework for improved healthandwell-being: 2013-2025’ publishedin consequences. what happensduringtheearlyyears haslong-lasting andlifelong effects and health, illness anddiseaseare influenced at different stagesofaperson’s life, and approach’ to foster healthy ageingacross thewholelifespan, since patterns of Both supra-national healthstrategies callfor along-term view or‘life-course procedures performed indefinedclinicalsettings. quality outcomes inadditionto themore publicisedattention onthenumberof systems managers.Additionally, evaluation shouldalsofocus onachieving high a system isbest gaugedfrom theperspective ofthe usersrather thanthe Another justification for citizens’ participation isthereality that thevalue of make to healthandsocialcare. citizens andthestate andto recognise andsupportthecontribution that thepubliccan Governments are beingincreasingly prompted to re-evaluate therelationship between healthy ageingprocess. promotion ofhealthanddiseaseprevention necessary for ahealthy life course anda environments’ withtheaimofreducing ofhealthinequalitiesandstrengthening the the creation of‘resilient communities’ (empowered persons) and‘supportive systems to improve governance ofandleadershipfor health.Health2020 advocates by EUandWHOstrategies asinstrumental. Bothpromote theneedfor health goal ofimproving thepopulation’s healthby thedifferent policy sectors, are seen government’ approaches promoting inter-sectoral working andownership ofthe The adoptionof‘Health inAllPolicies’ (HiAP)or‘whole-of-societyandwhole-of- ealth A in ultimately guarantee sustainability ofprogrammes. that itiscriticalto ensure community ownership, and that itisrequired to mobilisecommunity resources andto designmore effective services, the declaration that participation isanessential elementofcitizenship inademocracy, course (23) The Irishdocumentidentified that key life transition pointssuchasentering (26) (22) report oncommunity participation approaches andsustainable This principlehasbeensuccinctly documented inthe‘Healthy approach ll P (24) olicies (25) Participation stands for citizens takinganincreasingly

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3.6 3.5 dynamic H detection andtreatment ofhigh bloodpressure. of thoseat highriskofdisease such ascancer and cardiovascular diseases,includingearly fiscal measures, food product reformulation andscreening for, earlydetection andtreatment number of‘best buys’ inchronic noncommunicable diseaseprevention suchasincentive professionals to have a‘more flexible, multi-skilledand team-oriented workforce’. Health 2020 alsospeaksoftheneedto reform theeducation andtraining ofhealth 5. 4. 3. 2. 1. healthcare andimprove healthoutcomes. This involves: viable, fit for purpose, people-centred and evidence-informed’ health systems to provide quality identified priority. More specifically, Health 2020 identifiesthe requirement to have ‘financially The needto strengthen andsupportdynamichealthsystems isanotherinternationally investment that yieldsahandsomerate ofreturn. including inparticulardiseaseprevention andhealth promotion, shouldberegarded asan The World Economic Forum (2011) acknowledged that alarge amountofhealthspending, the reform ofhealthsystems. perceived assubstantially increasing productivity, andtherefore asaninstrument to support monitoring andmanagement concerning healthandlifestyle. These solutionsare often the range oftools that canbeusedto assist andenhance prevention, diagnosis,treatment, of healthsystems. These innovative solutionscanincludetheuseofe-healthwhichcovers use andsystem financingwiththeaimofimproving thequality, efficiency and sustainability innovative solutionsintheorganization ofhealthcare, modesofhealthcare delivery, resource by theEurope 2020. This programme willsupportinitiatives aimedat findingandapplying The ‘Healthfor Growth’ programme target areas ofactionare inlinewiththeagendaset considers ‘healthasavalue initself’ health andfor pushinghealthhighuponthepoliticalagenda.The European Commission This concept ispitched asacentral argument for justifying investment inthepopulation’s health andeconomic prosperity andportraying healthasa social andeconomic resource. Both WHOandtheEUCommission identifytheimportance ofhighlightingthelinkbetween thousands ofpremature deaths andchronic diseases. reduce highlong-term treatment costs andimprove healthoutcomes by avoiding tens of human capitalandpublicspending. People’s healthinfluences economic outcomes in terms ofproductivity, laboursupply, planning, working across sectors andleadershipcapacity. and long-term care delivery, skillsinsupportingpatient empowerment, enhanced strategic of thisreform shouldbeonteam-based delivery ofcare, new methodsofhealth,community ealth

focusing more oninnovative primaryhealthcare provision. ensure system transparency andaccountability aswell asto instill apatient safety culture, and the useofhealthtechnology assessments (HTAs) andqualityassurance mechanismsto reduction andelimination ofwaste, actions aimedat containment ofsupply-driven cost increases, working towards improving governance andleadership, , economic prosperity growth and health system (29) (29) (28) andasaprecondition for economic prosperity. S

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Focusing ondisease prevention can (31) The WHOhasalsoidentified a (24) The focus 31 Chapter 3 32 Chapter 3 †† 3.7

Demography and socio-economic situation; HealthStatus; HealthDeterminants; Healthservices andHealthpromotion. to monitor healthat theEUlevel. This ECHIlist comprises ashortlist of88indicators covering thefollowing themes: during thepast 14years. The aimofthisinitiative was to create acomparable healthinformation andknowledge system The European Community HealthIndicators (theECHIindicators) was created by theCommission andEUMember States

Monitoring as prerequisites for ‘healthplanning,implementation andevaluation’. health andwell-being status, onhealthneedsandsystem goalsandoutcomes’ The Health2020 strategy mentionstheneedof‘trustworthy, up-to-date information on Commission for anumberofhealth-related CSRsissued in2013. the long-term sustainability ofpublicfinances isthejustification presented bythe urgent reforms oflong-term entitlements,particularly healthandpensions,to underpin the sameyear eightcountries received aCSRonhealth(includingMalta).The needfor employment, research anddevelopment, poverty reduction andbudgetaryreform. In Furthermore, areview oftheNRPsin2012 found healthlinked to four themes,namely comprehensive analysis ofthecost-effectiveness ofhealth systems inMember States. AGS of2012 underthree ofthefive actionareas, the2013 AGS brought withitthefirst make explicit reference to health. Following theinclusionofHealthfor thefirst timeinthe (NRP) andCountry Specific Recommendations (CSR), whichsince 2012, have started to The Semester includestheAnnualGrowth Survey (AGS), National Reform Programmes reform coordination launchedin2011 inresponse to theeconomic crisis. European Semester isatwo stage annualprocess ofeconomic policy andstructural the introduction ofnew processes andstructures includingtheEuropean Semester. The in thebroader context oftheEurope 2020 Strategy. The reform process hasincluded through thelaunchofalong-term reform ofeconomic governance processes underway and financialcrisishasled to growing EUinfluence over national healthcare systems Despite thelimited competence oftheEUinarea ofhealthpolicy, theeconomic Performance Assessment (HSPA). and willbeeventually usedinthedesignandimplementation oftheHealthSystems The ECHIlist ofindicators hasalsoinformed theidentification ofindicators for theNHSS and over time) to inform policy makingandto measure performance. and importance ofhaving comparable healthandhealth-related data (between countries The ‘Healthat aGlance: Europe’ report publishedby OECDin2012 shows therelevance about current andforecasted future shortagesofhealthcare professionals. becoming stronger issues for healthsystems. The report alsohighlightstheconcern more prevalent whilst chronic diseasessuchasdiabetes anddementiaare increasingly identified. Tobacco consumption isdecreasing andthechallengeofobesitybecoming Member States andbetween socioeconomic groups. Achangeofriskfactors was also status hasimproved significantly inEuropean countries, large gapspersist between was basedontheECHIlist ofindicators††. The report pointsoutthat whilst health funding inthenew programming period2014-2020. health strategy inplace which‘contains amonitoring and review system’ to beeligiblefor performance isvery muchevident intherequirement setfor MemberStates to have a At anEUlevel, theemphasisonhealthoutcomes andparticularly healthsystem is spent,butalsohow itisspent,that determines acountry’s healthstatus. expenditure andhealthoutcomes isnotlinear. Therefore, itisnotonlyhow muchmoney European Commission alsoacknowledged that therelationship between healthcare H ealth (34) S

ystem S (35)

(24) (33) However, the This analysis (34) 3.9 3.8

C healthof systems R onclusion eforms needed to improve sustainability the health systems’ These recommendations are consistent withtheWHO’s ‘tenleadingsources ofinefficiency of ensuringthecost-effective useofmedicines;thisincludesincreasing theuseofless expensive • usinghealthtechnology assessment more systematically for decision-makingprocesses;• improving data collection andusingavailable information• to underpintheimprovement better health promotion anddiseaseprevention inandoutsidethehealthsector; • reducing theunnecessary useofspecialist andhospitalcare whileimproving primary • ensuringabalanced mix ofstaff skillsandanticipating staff needsdueto ageing; • encouraging more cost-effective provision• anduseofhealthservices through where structural reforms andefficiency gains couldimprove thesustainability ofhealth systems. The European Commission andtheEconomic Policy Committee identifiedthe following areas approach over thenext few years. strategic actionsthat willleadtowards theattainment ofthesegoalsthrough apeople-centred objectives andstrategic directions oftheNHSS. These willbefollowed by thepresentation ofthe strategies. Inlinewiththisevidence anddirection, thefollowing chapters willsetouttheoverall in Maltaare andwillbefacing inthecoming years andthoseidentifiedinsupra-national health There are several similaritiesandcongruencies between thechallengesthat thehealth systems equivalent (generic) drugs. efficiency ofhealthsystems; European Community HealthIndicators (ECHI)anddeveloping tools to better assess the of theperformance ofhealthsystems; inparticularthecollection ofhealthdata usingthe healthcare services; adequate incentives; (37) andtheOECD’s recommendations for healthsystem reform.

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33 Chapter 3

H the for goals Setting the Chapter 4 4.1 I ealth Systemsealth Strategy ntroduction which form thepillarsofNHSS. Box 4presents thefour overall objectives andthecorresponding seven strategic directions responsible for eachactionorsetofactions. of appropriate timeframes andestablished accountabilities for theentitiesidentifiedas sought, obtainedandemployed. Itwillbefollowed by anagreed actionplaninclusive demonstrating how andwhat human,intellectual and financial investments needto be means by whichthenational health systems willtacklethesechallenges.The strategy is strategic directions over thenext few years. These strategic actionsdemonstrate the national healthsystems to achieve eachoftheoverall objectives andtheircorresponding the strategic actionsandtacticsthat theMinistry hasidentifiedasnecessary to helpthe of theseoverall objectives andrespective strategic directions. Chapter 7willelaborate these overall objectives andstrategic directions. Itwillalsopresent therationale for each This chapter isdevoted towards an illustration oftheunderstanding oftheMinistry on objectives willbeapproached. Each direction isintended to list and explain theroute orroutes through whichtheoverall The four overall objectives have eachbeenelaborated withtwo orone strategic directions. population upto 2020 andbeyond. the Ministry responsible for Healthfor thenational healthsystems andthehealthof national strategy. These overall objectives are intended to cover andleadto thevisionof past 20years andthedeliberations ofthetaskforce that was created in2012 to draft this review oftheaccumulated thematic strategies andpolicy documentsissued over the objectives. These objectives encompass thestrategic policiesidentifiedfrom anin-depth The National HealthSystems Strategy (NHSS) evolves around asetoffour overall

35 Chapter 4 36 Chapter 4 Box 4|ThepillarsoftheNHSS of-society approaches. being to influence national decisionsthrough whole-of-government andwhole- Improving governance andempowering future leadership for healthand well- Strategic Direction 4B financing mechanisms,entitlementcriteria for care andorganization of care delivery. Designing, developing andevaluating sustainable policiesfor humanresources, Strategic Direction 4A Ensure thesustainability oftheMaltese HealthSystems. Overall Objective4 service provider teams andby improving communication andsharingofinformation. Facilitating continuity ofcare through co-ordination andintegration withinandbetween Strategic Direction 3B development andsystematic application ofcasemanagementprotocols. Setting andenforcing qualitystandards includinglicensing andaccreditation and Strategic Direction 3A health workers supported by robust information systems. Improve qualityofcare by ensuringconsistency ofcare delivered by competent Overall Objective3 prioritisation, monitoring, publicprivate partnership, andotherservice provision models. Improving managementandefficiency ofservices through research andinnovation, Strategic Direction 2A medicines andhealthtechnologies. Increase equitableaccess, availability andtimeliness ofhealthandsocialservices, Overall Objective2 and control ofdiseaseprogression. changes andlifestyle choices includingprotection, screening andearlydiagnosis Strengthening theprevention andpromotion ofhealthfocusing onbehavioural Strategic Direction 1B dependency care. Prolonging stay inthecommunity andresponding to increasing demandsfor higher Strategic Direction 1A vulnerable. epidemiological trends focusing onthewholecourse oflife, children, theelderlyand Respond to increasing demandandchallengesposedby thedemographic changesand Overall Objective1 OVERALL OBJECTIVESANDSTRATEGIC DIRECTIONSOFTHENHSS IMPROVED HEALTH, INNOVATING THEWAY FORWARD:

4.2

AND COMMUNICATIONAND TECHNOLOGY (ICT) STRATEGICTHE OVERARCHING ROLE INFORMATION OF promoted amonghealthprofessionals andthegeneral public. term training andlonger-term educational opportunities.Knowledge ofhealthICTwillalsobe to deliver thisstrategic plan.This specialisedcommunity willbedeveloped through short- The existing cadre ofhealthICTpractitioners willbeidentified, recognised andempowered 6. Devel identification andauthentication) will bepursuedand,where possible, common Government services willbeincorporated (e.g. for datasets willbeestablished, includinghealthprofessional registers. Interoperability of services desktop infrastructure according to theirbusiness needs.Acommon repository ofkey health All Government healthcare delivery sites willbeprovided withconnectivity andup-to-date 5. Es resources, achieve value for money, andlay thebasisfor research anddevelopment. based onagreed policiesandstandards, to facilitate thecontrolled sharingofdata and The development ofhealthICTsystems willbecoordinated through acorporate architecture 4. Create ascalablec patient safety through decisionsupport,anddirect patient involvement. Systems willbedeveloped that facilitate continuity ofcare, fast andefficientservice delivery, 3. Empower health professionals andp materials. by achieving better healthoutcomes, increased productivity andcost savings onlabourand Investment inhealthICTwillbegeared to bringbenefit to thehealthcare system asawhole 2. A care andto strengthen coordination between acute care andcommunity care settings. friendly for patients, family doctors andcommunity pharmacists, insupportofbetter primary The existent myHealth ande-healthsystems willbedeveloped furtherandrendered more user- 1. Devel that theMinistry willbeimplementingto reach itsstrategic objectives anddirections. in Healthhave beenspecificallyhighlighted inChapter 7that isdetailingtheactionsandtactics robust information systems. Consequently, actionsrelated to thedevelopment ofICTsystems ensure qualityandconsistency oftheservices delivered that canonlybeprovided through particular ofOverall Objective 3that mandates thesupportthat isrequired to improve and objectives anddirections are congruent withtheoverall philosophy oftheNHSS andin A numberofstrategic objectives andstrategic directions have already beenidentified. These e-health over thenext few years. and prioritisetheessential elementsthat willguideinvestment and activityinHealthICTand addressed through thedrafting, endorsementandimplementation ofastrategic planto identify information andcommunication technologies (ICT)to Malta’s healthsystems. This isbeing There isagreat andgrowing demandfor efficient, effective, and economicapplication of chieve bettervalue fo r money tablish arobu op themyHealth ande-health s op Malta’s humanca pital inhealthICT t andinteroperablehealth ICT infra orporate health ICTarchitecture . y atient s tems s throughICT s tructure 37 Chapter 4 38 Chapter 4 4.3

THE RIGHTCAREAT THERIGHTPLACE AT THERIGHTTIME Strategic Direction 1A society. productive, andhealthy olderpeoplecancontinue to contribute actively andfor longerto development. Healthy children have thecapabilityto learnbetter, healthy adultsare more health andequitybeginswithpre-conception, pregnancy, peri-natal andearlychild health, preventing anddelaying theonsetandimproving control ofdisease. Improving requires aneffective life-course strategy that gives priority to new approaches to promoting place andisexpected to continue developing inthepopulation oftheMaltese Islands economic, societalandindividualbenefits. The demographic transformation that hastaken diseases (longevity dividend).Improvements onbothofthesegoalscanyieldimportant chances for andthespanofhealthy life expectancy anddelaying theonsetofage-related Investing andsupportinggoodhealththroughout thelife-course leadsto increasing the groups. epidemiological trends focusing onthecourse oflife, children, theelderlyandvulnerable Respond to increasing demandandchallengesposedby thedemographic changesand HEALTH ANDWell-being THROUGHUTLIFE Overall Objective 1 objectives seven and strategic directions T rationalehe overall four the behind working. informal care inthecommunity andasnearpossible to where peopleare residing and empowering andencouraging communities to become more involved intheprovision of upgrading allsettingsproviding healthservices andthere willbeincreased focus on and well-being ofthepersonneeding thecare. Actions needto betaken to continue is most suitableto theneedsandconducive to sustaining andimproving thehealth Action willbetaken to ensure that thecare required isdelivered inthesettingwhich disciplinary andteam-oriented delivery ofcare. delivery supportingindependentliving inthecommunity andpromoting more flexible, multi- the useofinnovative tools suchascommunication technology andnew forms ofservice participate innew ways intheirtreatment andtake better care oftheirown health,increasing as thecornerstone ofthehealthsystem by fostering enablingenvironments for peopleto care. Primaryhealthcare needsto increase itseffectiveness and consolidate itsposition in primarycare, rehabilitation andcommunity services, andhigherdependency long-term needs more appropriately andto achieve better value from theavailable capacityparticularly investment across thesystem andre-orientation ofexisting services isrequired to meet increasing thecapacityto meetthecurrent andforecasted increases indemand.Additional It isbecoming increasingly evident that thenational healthsystems needsto invest in care. Prolonging stay incommunity andresponding to increasing demandsfor higherdependency ENSURING EQUITYWITHIND Overall Objective 2 ENGAGEMENT ANDEMPOWERMENT T Strategic Direction 1B (39) will buildonthis.Values relating to improving healthmust includereducing inequitiesinhealth. equity andsolidarity. Anew statement oncommon values for healthpolicy inthebroader sense healthcare systems, listing theoverarching values ofuniversality, access to goodqualitycare, In June2006theCouncil adopted astatement oncommon values andprinciplesinEU health technologies. Increase equitableaccess, availability andtimeliness ofhealth and socialservices, medicinesand consumer protection. and injuries,improving workers’ safety, andactionsto ensure andsafeguard food safety and bioterrorism, strategies to tacklerisksfrom specificdiseasesand conditions, actiononaccidents threats. These includehealthimpactassessments, preparedness andresponse to epidemicsand protect humanhealthandimprove safety, securityandprotection ofcitizens against health This strategy alsoaffirmsthe continuation and consolidation ofinitiatives and resources to ultimately leadto ahealthierlife course andahealthierageingprocess. health inequalitiesandthestrengthening ofhealthpromotion anddiseaseprevention. These will direct actionby theMinistry responsible for Healthinthisregards willresult inthereduction of of ‘resilient communities’ (empowered persons) and‘supportive environments’. Advocacy and accidents inthehome. This isincongruence withtheHealth2020 recommending thecreation and drugs,environmental andoccupational healthandsafety risks, road traffic accidents, and nutrition, low levels ofphysical activity, tobacco consumption andharmfulintake ofalcohol prevent diseasethroughout thelifespan by tacklingkey issues including poorandunbalanced could besubstantially reduced. succeed inremaining healthy asthey live longer, theriseinhealthcare spendingdueto ageing the poolofpeopleinworking population. However, EUprojections show that ifpeople changes are likely to continue raising thedemandfor healthcare services whilealsodecreasing rates iswell established andwillbeacontinuing phenomenonintheforeseeable future. These The ageingofthepopulation inMaltaresulting from increasing longevity andfalling birth population ismademore possible. so theindividualandcollective contribution to improving theoverall healthstatus ofthe and supportmakingthehealthierchoice to become theeasierchoice isrequired. Indoing is notthesoleresponsibility oftheindividual.The creation ofenvironments that facilitate potential for longevity. However, theachievement andmaintenance ofhealthandwell-being People’s lifestyles andtheconditions inwhichthey live andwork, influence theirhealthand choices includingprotection, screening andearlydiagnosiscontrol ofdiseaseprogression. Strengthening theprevention andpromotion ofhealthfocusing onbehavioural changesandlifestyle considered. effectiveness andequity, andhealthprofessionals’ training andcapacity implications must be attain their fullpotential inlife. New programmes must beevaluated properly, includingfor cost- identified inorder to ensure that services are non-discriminatory andenablethesepeople to in healthstill exist between population sub-groups. These sub-groups needto beproperly Althoughmany Maltese enjoy alonger andhealthierlife than previous generations, inequities YNAMIC HEALTH S (38) Action willcontinue to betaken to promote healthand O PRM Y S TEM ANDENSUREU TE HEALTH TAINED PROGRESS 39 Chapter 4 40 Chapter 4 A JOINTEFFORT T Overall Objective 3 MAKING BES Strategic Direction 2A standard ofcare that isstill cost effective. for training ofhighlyqualifiedprofessional, canassist intheachievement ofahigher of theirown health.Makingfulluseof 21st-century tools, innovations and possibilities to thrive, andencouraging peopleto participate intheirtreatment andtake better care emerging healthsystems needsby fostering anenablingenvironment for partnerships the present international standards for goodpractice inthisfield. They can respond to care isanotherimportantsector that requires majordevelopment to bringitinlinewith community care are two importantcornerstones ofthehealthsystems. Mentalhealth systems that are fit for purpose, people-centred and evidence-based. Primaryand Achieving high-qualitycare andimproved healthoutcomes requires sustainable health workers supported by robust information systems. Improve qualityofcare by ensuringconsistency ofcare delivered by competent health financially viable, fit forpurpose, people-centred and evidence-informed andbased. quality andefficiency standards through ahealth system that becomes increasingly Action willconcentrate to achieve andmaintainservices that assure highlevels ofsafety, technologies andmedicines,migration, andmobilityofpatients andhealthprofessionals. expectations, demandsfor theintroduction ofnew, more expensive andsophisticated in response to thechallengespresented by anageingpopulation, risingcitizens’ The national healthsystems are underconstant andescalating pressure to act economically andclinicallyefficient,while keepinginmindethicsandequitability. are taken have to beevidence basedandnew initiatives that are embarked onhave to be recognised that services needto beplannedwithavision ofthefuture. Decisionsthat putting anincreased financialburden onfuture generations. Itisbecoming increasingly of current andfuture service provision withinadynamichealthsystem andavoid These concepts ofmacro- andmicro-management ofservices willensure thecontinuity possibility ofpublicprivate partnerships,community frameworks ande-healthsolutions. New emerging concepts needto bekept inmindandutilisedwhennecessary, suchasthe disturbing resources. While at thelevel ofservice provision, technical efficiency isamust. and efficiency. At Government level efficiency needs tobeachieved whenallocating and of andthedifferent players inthe system are utilised to theirmaximumeffectiveness needs ofindividualsandfamilies, itisalsoconcerned withensuringthat thevarious parts Whilst thehealthsystem needsto re-organise itselfto become more responsive to the prioritisation, monitoring, public private partnership, andotherservice provision models. Improving managementandefficiency ofservices through research andinnovation, T USEOFAVAILABLE RESO URCES O ENSUREC ONTINUITY OFCARE S Strategic Direction 3B ES Strategic Direction 3A AFE, HIGHQUALITY ANDEFFICIENT SERVICES continuity ofcare isensured andpatients are not‘lost’inany partofthesystem. The ultimate aim achieved iftheactivitiesofdifferent players inthecare delivery pathways are integrated so that Continued qualitydevelopment andperformance enhancement ofthehealthservices canonlybe Policies, andincreasing visibilityandunderstanding abouthealthwithallstakeholders. out implementation mechanismsfor cooperation between partners,reinforcing HealthinAll and integrated communication andinformation systems are indispensable. This strategy sets systems to work efficientlywithina framework that is stillsafe forthe patient, comprehensive synergistic cooperative actionbetween hospitals andcommunity care. However, for such resources we have to promote healthsystem modelsthat enhance continuity ofcare through In order to improve qualityofcare, minimiseinequities andmake thebest useofhealthcare provider teams andby improving communication andsharingofinformation. Facilitating continuity ofcare through co-ordination andintegration withinandbetween service collective public healtharena. more intherole ofdecision-makers at boththelevels oftheirindividualcare aswell asinthe and endorsedonanational level andcitizens willbeencouraged andsupported to engage patient outcomes are importantprinciples.Patients’ rightsandresponsibilities willbedefined Furthermore, recognizing patients asaresource andaspartners,beingaccountable for are averted. such that factors leadingto mishapsare corrected andrepetitions ofreported adverse events whole healthsystem bothat thelevel oftheindividualoperator aswell asat thesystems level patient safety policy andsupportinglegislation. The aimisto foster alearningculture inthe conduct andbest practice care guidelines,andtheimplementation ofahealthsystem-wide trained professionals that respect andoperate withintheestablished professional codes of complements ofhealthcare facilities andequipment,ensuringtheavailability ofqualifiedand of qualitystandards. These willincludetheenforcement ofappropriate standards for and regulatory andleadershipfunctionsstructures particularlyinthesector for theapplication systems. This strategy ispromoting theconsolidation andcontinuing development ofthehealth and accountability andfor fostering people’s trust andconfidence inthenational health systems. Qualityassurance mechanismsare especiallyimportantfor healthsystem transparency Ensuring andenhancingapatient safety culture isanintegral partofthenational health performance andpatient satisfaction. citizens, consumers andpatients iscriticalfor improving healthoutcomes, healthsystem as competences neededfor wellbeing, including‘healthliteracy’. key starting point.This includesparticipation inandinfluence ondecision-making,as well health system. Healthpoliciesandstrategies must take citizens’ andpatients’ rightsasa individualised, withthepatient becoming anactive subjectrather thanamere objectofthe keeping patient safety inmind.Healthcare isbecoming increasingly patient centred and encouraged inorder to provide better qualityofcare to patients, thishasto bedonewhile field are advancing at a fast rate. While theintroduction ofsuchnew technologies is Patient safety isat thecore ofevery healthcare system. Technologies inthemedical and systematic application ofcasemanagementprotocols. Setting andenforcing qualitystandards includinglicensing andaccreditation and development TABLISHING TAND ARDS WITHINAP

ATIENT -CENTERED APPRO ACH (39) Empowering people, 41 Chapter 4 42 Chapter 4 INTEGRATED PLANNINGA Strategic Direction 4A WORKING T Overall Objective 4 creative andinnovative responses to whichthere isareal commitment. the increase inthedemandfor healthservices whilestill remaining sustainable through market, itisbecoming increasingly importantto ensure that healthsystems cancope with resourced. Intheambitofanageingpopulation andadecrease inthelabourworkforce and thepotential ofpersonalisedmedicinewillbepromoted. effective, patients will continue to become more empowered to undertake self-care practices health system. Service delivery willberelocated ascloseto homeasissafe andcost- will bestrongly reinforcing therole ofprimaryhealthcare asthecornerstone ofthenational and where necessary between thehealthcare andthesocialcare services. This strategy primary, secondary andinstitutional care, between theprivate andpublichealthcare sectors is to introduce aseamless process ofcare for any particularpatient between community, future generations. consequences suchasunnecessary financialburdens willnothave to beimposed on allowed to continue enjoying thebenefitsoffered by our health system andpossible rationale for thisactivitycentres ontheintention that thecurrent population willbe will alsobeincreasingly evaluated to ensure they are beingdelivered efficiently. The economic andcost-effectiveness evaluations ofany new initiatives. Existing services care services that canreach standards ofexcellence. Emphasiswillbeplaced on policies willbedesignedto assist inthe continuous delivery ofsustainable health its services free ofcharge at the pointofuse. Inorder to tacklethischallenge, population isputtinganincreasing burden onthepublichealthsystem whichdelivers from theprivate to thepublichealthcare system. This together withtheageing in anunexpected shiftofasignificantnumberpeopleanddemand for services The openingofthenew Mater Dei Hospital, astate ofthearthospital,hasresulted any changesthat needto bemadewithintheexisting frameworks. outcomes to enableproper evaluation ofthepolicy to analyse itseffectiveness andjustify the future. This concept hasto be incorporated inallpolicies,together with measurable necessary humanresources, infrastructure andfinancialinvestment canbe sustained in future, inorder to ensure, that priorto embarkingonnew initiatives itisassured that the economic evaluations withinhealthsystem willgainincreasing importance inthecoming boundaries, expand transparency, andstrengthen accountability. The useofhealth There isanincreasing needto applyevidence to policy andpractice, observe ethical mechanisms, entitlementcriteria for care andorganization ofcare delivery. Designing, developing andevaluating sustainable policiesfor humanresources, financing the sustainability ofhealthandwelfare systems. threats andfinancialuncertainties make improving health even more difficultand threaten Rapid growth ofchronic diseaseand mental disorders, lackofsocialcohesion, environmental Ensure thesustainability oftheMaltese HealthSystems. OW ARDS SU

S ANESSENTIAL P TAINABLE HEALTH S ART OFSU Y (24) S TEMS Allresources are finite, includinghuman TAINABLE HEALTH S

Y S TEMS IMPRO Strategic Direction 4B on board thesechallenges. be implemented. Awell equippedcomplement oftrained professionals willbeneededto take remain strong assets withinthisstrategic managementplanthat willrequire various changesto building amongawidevariety ofstakeholders. Responsibility, ownership andaccountability will tactics andactionswillbetaken to secure coordination through normative values andtrust- societal level through whole-of-societyapproaches that willcomplement publicpolicy. Various Governance andleadershipwilldevolve beyond theMinistry’s level. Itwillbereinforced alsoat recognising how healthalsoaffects othersectors. all policiessothat allsectors willunderstand andacton theirresponsibility for healthwhile government stands. More advocacy willbeengagedto emphasisetheconcept ofhealth in for better coordination andintegration, centred onthe overall societalgoalsfor whichthe requires buildingtrust, common ethics,acohesive culture andnew skills.Itstresses theneed government actionswhichincreasingly involve alsogroups outsidegovernment. This approach Whole-of-government activitieswillbeembarked onwhichare multilevel (from localto global) Actions willbetaken to improve leadershipandparticipatory governance towards health. approaches for healthandactingasbrokers andadvocates. groups andpublichealthagenciesare increasingly engagedininitiating inter-sectoral and stakeholders andvice versa. The Ministry responsible for Healthtogether withpatient strategies anditalsohasto consider how itshealthpolicy decisionsaffect othersectors The healthsector isresponsible for developing, implementingandevaluating national health need to beestablished andpatient groups needto beencouraged, strengthened andfacilitated. Formal structures andprocesses that supportcoherence andinter-sectoral problem-solving burden ofdisease. This isalready occurring locallyhowever itneedsto bestrengthened. Leadership at Ministerial level andfrom healthagenciesisvitallyimportantto address the through whole-of-government andwhole-of-societyapproaches. empowerement offuture leadershipfor healthandwell-being to influence national decisions at successfully achieving real improvements inhealth.This needsto besupported through the Improving governance andparticipatory governance for healthiskey to governments aiming VING LEADERSHIP:P

ARTICIP AT ORY GO VERNANCE FOR HEALTH (24) 43 Chapter 4

Systems Strategy Systems N objectives of the illustrating overall the K Chapter 5 5.1

ey baseline indicators indicators ey baseline ational H I ntroduction Assessment (HSPA) whichhasbeenproceeding inparallel withthedevelopment oftheNHSS. date isconsidered asinadequate. This work willbepartoftheHealthSystems Performance that will helptowards improving themonitoring oftheareas ofthehealthsystems whichto deliverables oftheNHSS willinvolve thedevelopment ofindicators andinformation channels for whichrelevant available information was missing, insufficientorincomplete. One ofthe The exercise that hasbeenundertaken to elicitthisinformation hasalsoidentified several gaps 4. 3. 2. 1. four overall objectives ofthisstrategy. These include: Indicators andrelated information willbepresented according to thekey issues identifiedinthe may needto beutilisedinthemonitoring process ofthisstrategy. indicators that are presented inthischapter are notexclusive andmore ordifferent indicators inter aliatheimplementation andtheexpected outcomes ofthisstrategy over time. The indicators isinfluenced by theneed to have ongoinginformation that canbeused to monitor the present situation ofdifferent aspects ofthehealth systems inMalta. The identification of Several indicators canbeutilised to illustrate andbetter understand thefactors influencing The needfor along-term visionfor thesustainability ofourhealthsystems protocols and/or international guidelines Quality ofcare includingpatient safety, continuity andconsistency ofcare, implementation of Access, availability andtimeliness ofservices, medicinesandmedicaltechnologies ageing andvulnerable groups Increased demandandchallengesdueto demographic changes,epidemiologicaltrends, ealth ealth

45 Chapter 5 46 Chapter 5 ** Income inequalitydistribution ratio: The ratio oftotal income received by the20%ofpopulation withthehighest unemployment rate:* Harmonised This represents unemployed personsasapercentage ofthelabourforce basedon 5.2 as equivalised disposable income. income (top quintile) to that received by the20% withthelowest income (lowest quintile). Income must beunderstood job to start withinthenext three months.Data are presented inseasonallyadjusted form. start work withinthe next two weeks; andhave beenactively seekingwork inthepast four weeks orhadalready found a Unemployed personscomprise personsaged15to 74 who:are withoutwork duringthereference week; are unableto International labourOffice (ILO) definition. Thelabour force isthe totalnumberofpeopleemployed andunemployed.

AGE 40-44 60-64 50-54 30-34 45-49 20-24 65-69 55-59 35-39 25-29 70-74 10-14 15-19 75+ 0-4 5-9 trends to changes demographic I A. Demography demand challenges and ncreased due 30 Source: Demographic Review 2010 projections reveal acontinuous forecasted trend ofincreasing ageingofthepopulation. youths under20willdecrease from 90,705 to around 59,300 -adrop of35%. These when compared to thissegmentofthepopulation during2010. By 2060, children and aged 65years andover isprojected to increase to around 111,700 –anincrease of72% 2025 andgo down to just over 350,000 personsby 2060. The population ofpersons Office indicate that thepopulation ofMaltais expected to reach429,000 persons by 1,000 population. (5)The population projections publishedby theNational Statistics rate was 1.4birthsperwoman. This islower thantheaverage EUrate of1.54birthsper The crudebirthrate for 2012 was 10.1 birthsper1,000 population andthetotal fertility distribution ratio** was 4.1 whilst theEUaverage is5.1 for 2011. favourably withtheaverage EUrate of10.7% for thesameperiod.The income inequality The harmonisedunemployment rate* inMaltafor 2012 was 6.9%.This compares individuals aged65years andover andjust over halfthepopulation (50.26%) were females. of thetotal population. At theotherendofspectrum,16%total population were total population ofchildren andyoung peopleunder theageof18years amounted to 18.4% The total population inMalta,from themost recent census conducted in2011, is417,432. The acknowledged andcatered for. these trends are resulting inincreasing demandsandchallengeswhichneedto be significantly impacttheperformance ofthenational health system. Ingeneral Demographic andepidemiologicalchangesinthepopulation oftheMaltese Islands 25 Figure 1| 20 15 10 5 2010 , ageing groups vulnerable and 0 5 Population p Islands in2010, 2025 an d 2060 10 15 (40) 20 25 30 35 30 yramids fo r population oftheMaltese 25 20 15 10 men 5 2025 0 5 women 10 , epidemiological 15 (2) 20 25 30 35 30 (40) 25 (40) 20

15 10 5 2060 0 5 : 10 15 20 25

30 (61) (2) 35

40-44 60-64 30-34 50-54 45-49 20-24 65-69 55-59 35-39 25-29 70-74 10-14 15-19 75+ 0-4 5-9

AGE females and61.7 years for males. and 70.3 years at birthfor malesin2011 whichishigherthanthat for theEUat 62.2years for also accompanied by anincrease inhealthy life years (HLY): 70.7 years at birthfor females all cancers per1,000 population. compared to 51.64deaths for stroke and151.64deaths whencompared to 166.85deaths for population. However, theSDRfor stroke andallcancers was lower; 42.48deaths when population whichishigherthantheaverage EUrate (2011) of80deaths per100,000 Death Rate (SDR)for IschaemicHeartDiseasein2012 was 143deaths per100,000 being diseasesofthecirculatory system (unchangedfrom previous years). The Standardised crude death rate was 7.86 deaths per1,000 population withtheleadingcauseofdeath Over thepast 10years themortalityrate inMaltahasseenadownward trend. In2011, the expectancy at birthfor maleswas 78.8 years whilefor females itwas 83.1 years. Life expectancy hasseenaremarkable increase over thepast 30years. In2011, thelife Note: *ESP=European Standard Population Source: AnnualMortalityReport –2012 for countries intheEU. T All othercauses ( Malignant neoplasmofbreast ( Chronic lower respiratory diseases Diabetes mellitus(E10-14) rectum &anus( Malignant neoplasmofcolon, Dementia (F01-F03) infections ( A including heartfailure (I50) Other heartdiseases(I26-51) bronchus &lung( Malignant neoplasmoftrachea, C Ischaemic heartdiseases(20-25) Cause ofdeath (ICD-10 code) table 6|Leadingcau se ofdeath by number,rate andpercent C50) J40-47) otal erebrovascular diseases(I60-69) cute lower respiratory tract J12-22) C18-21) C33-34) (40) (5) (6) (6) (40) Infact females inMaltatop thelist for HLY at birth 1489 608 103 319 122 60 60 45 47 53 72 M Number ofdeaths 0 1521 553 328 160 56 79 92 75 37 72 18 51 F 3010 647 263 103 1161 120 159 125 152 90 79 111 T 626 261 132 49 43 29 26 24 23 19 18 M population (ESP)* 0 SDR per100,000 429 169 26 85 25 16 41 18 18 15 13 F 5 (6) 107 517 20 211 42 29 25 14 14 19 18 17 T (5) This was

38.6 100 21.5 4.0 3.0 5.0 3.4 4.2 2.6 5.3 8.7 3.7 % of total deaths 47 Chapter 5 48 Chapter 5 B. Lifes births, whichisabove withtheEUaverage of4deaths per1000live birthsin2011. The average infant mortalityrate for theperiod2010 to 2012 was 5.1 deaths per1000live SDR =Standardised Death Rate (usingtheEuropean Standard Population) Note: Eurostat Statistical Data -Healthy Life expectancy; Fertility rate Malta1980 European Healthfor Alldatabase, WHO Sources: and monitoring theimplementation ofstrategies. useful for determining policy priorities,projecting demandon thenational healthsystems and compare performance across population groups orgeographic areas, andcanbe health-related behaviour that influence thehealthofapopulation. They help usanalyze Lifestyle indicators are importantasthey give usaclearpicture offactors related to routinely andtermination ofpregnancy offered. compared to othercountries where screening for congenital anomaliesispracticed This greatly influences theinfant andchildhoodmortality rates inMaltaespeciallywhen with potentially fatal congenital anomaliesisoften bornalive butpasses away after birth. is importantto note that termination ofpregnancy isillegalinMalta.Afoetus diagnosed mortality: (SDR)* Disease-specific Health expectancy: HLY inyears T Life expectancy at birthinyears Crude birthrate: (per1,000 population) Crude death rate: (per1,000 population) Indicators table 7|Demographicandeiemi l otal fertility rate: (birthsperwoman)

tyle indicat

and EU-15 for 2010 ors (5) mortality -rate Infant All Cancers Stroke Heart Disease Ischaemic Females Males Females Males ogical d ata for Malta, EU-27 202.2 Malta 1980 151.4 413.1 72.8 67.9 N/A N/A 15.5 17.6 2.0 9.1 Malta 106.4 2010 83.6 42.5 151.7 70.2 79.3 71.6 9.6 5.5 7.2 1.4 EU-27 2010 167.7 62.6 77.2 80.1 10.7 51.6 61.7 83.1 9.7 1.6 4.1 (5) EU-15 (2009) 160.7 2010 84.0 60.3 78.6 N/A N/A 10.8 37.7 It 3.6 9.3 1.6 and intheHBSCaverage. percentage ofboys whoare obeseoroverweight isalso larger thanthat ofgirlsbothinMalta is above theHBSCaverage in2010 across allagesfor bothboys andgirls.At EUlevel, the obese oroverweight increased at theagesof11and13butdecreased at theageof15.Malta all agesexcept at age11where there was aslightincrease. The percentage ofboys whoare overweight. The percentage of girlswhoare obeseoroverweight decreased since 2006across carried outinschoolchildren in2010 about26%ofgirlsand35% ofboys are obeseor obese females. Maltese menare themost obesemalesinEurope whilst Maltese women are thethird most i. Obesity collaboration withlocalcouncils invarious localitiesaround Malta. also offers community aerobics services by offering free aerobics classes which are heldin to clientswhere theweight managementprogramme was deemedinappropriate. The unit increasing inpopularity. One-to-one counselling service for weight managementisalsogiven Weight ManagementProgrammes whichare heldinvarious settingsandhave proven to be more activitiesthat they trulyenjoy. of 2012 involved introducing young peopleto different sportssothat they may take uponeor to walk to schools situated inthesamelocality, whileapilotproject carriedoutinthe summer introduction ofthe“Walking Bus”initiative by theHPDPDaimsat encouraging schoolchildren The needfor more physical activityisalsobeingpromoted especiallyfor children. The and onhow to prepare age-adequate, healthy mealsandsnacks. educating parents ofchildren aged0-3 years, ontheimportance ofappropriate weaning foods number ofinitiatives. These includethesettingupofapilotservice ofchildobesityclinics, Promotion andDiseasePrevention Directorate (HPDPD) istacklingthisproblem through a Obesity, andespeciallychildhoodobesity, isanimportantnational concern. The Health Source: HealthBehaviour inSchoolChildren 2010 11 years table 8|Percentage of childrenreported t 13 years 15 years acc (10) ording t According to theHealthBehaviour inSchool-agedChildren (HBSC)survey B B B Girls Girls Girls oys oys oys (41) o BMI,ages 11-15 2002 N/A N/A 20 34 24 28 (41) 2006 30 28 25 32 o be 31 31 ver weight orbese 2010 26 29 28 23 37 41 average 2010 HBSC 10 18 13 17 17 11 49 Chapter 5 50 Chapter 5 who smoke regularly intheEU. aged 15years and over whosmoke regularly was 20.4% in 2008–lower thanthe23.92% smokers hasbeensmokingfor 10years orless. to theEuropean HealthInterview Survey (EHIS)2008,thelargest percentage ofdaily Even thoughmalesstill smoke more thanfemales, thegapisgettingsmaller. According iii. Smoking Source:MONICA study andEHES2010 the MONICA High bloodpressure (hypertension) intheMaltese population hasimproved overall since ii. Highbloodpressure andbloodcholesterol levels Source: HealthPromotion andDiseasePrevention Directorate, 2013 levels have alsodecreased significantlyduringthisperiod. European HealthExamination Survey (EHES)heldin2010. Similarlybloodcholesterol readings. These figures increased to 66.9%inmalesand68.7% in females inthepilot time, 51.5%of malesand52.9% offemales were found to have normalbloodpressure disease) study in1984whichmeasured theblood pressure level ofparticipants.At that Desirable BloodCholesterol Normal BloodPressure Service Y table 9|Numberofcla table 10|Changesinpercentages ofnormalbl A management Weight ear erobics by theHealth Pr om Weight Management andAerobicscla (44) desirable bl (aged 25-64)–c (Multinational MONItoring oftrends anddeterminants inCardiovascular classes o. of No. of 14 14

2010 ood choles sses andnumberofp participants omp (5) o. of No. of 234 263 aring d tion Females Females Males Males terol levelsinMalte se adult (43) classes o. of No. of ata from1984and2010 28 32 (17) The total percentage ofMaltese people

2011 participants articip Percentage ofMaltese adults o. of No. of 839 ood pressure an d 521 (12) sses organized 1984 52.9 22.9 51.5 21 (aged 25-64years) ant s at classes o. of No. of 42 38 (12) (44)

2012 s 66.9 2010 68.7 participants 31.3 44

o. of No. of 802 972 Source: European Health for Alldatabase, WHO did notdrinkalcohol inthepast 12monthswhile5%drank alcohol onadailybasis. The European HealthInterview Survey (EHIS)2008found that about33%oftheparticipants iv. Source: HealthPromotion andDisease Prevention Directorate, 2013 SmokingCessation Classes are provided invarious settings.One-to-one counseling on • The Quitlineisavailable for thegeneral publicwanting to seeksupportrelated• to smoking following initiatives: The HealthPromotion Unitprovides Tobacco Dependence SupportServices whichincludethe 39% for thewholeESPAD study population. the previous 30days was 56%.The average figure for heavy episodicdrinking was noted to be students inMalta whoreported in2011 that they hadengagedinheavy episodicdrinkingduring during theprevious 30days, compared to 57% whichistheESPAD average. The proportion of to sixteen year oldEuropean students from 36countries surveyed, hadconsumed alcohol European SchoolProject onAlcohol and otherDrugs(ESPAD) study found that 68%offifteen (2008) %aged15+ R Indicators table 12|Data onsmokingandalc Y table 11|Numberofcla cessation Smoking (Litres percapitaaged15+),2010 T community services. quit andisusuallydonethrough anappointmentwhensmokers are notableto useother tobacco cessation isalsoprovided. This isoneofthemost effective ways to helpaperson three callsaday, averaging around 750 callsinayear. cessation orto applyfor smokingcessation classes. Onaverage theQuitlineanswers to about otal (pure) alcohol consumption (sales) Alcohol consumption ear egular smokers – Clinics organizedby theHealth Pr om classes No. of 25 (43)

T Females Males otal 2010 sses andnumberofp participants o. of No. of 223 ohl c (14) classes No. of 16 onsumpti Malta 20.4 25.6 7.62 15.8 2011 articip participants tion Unit o. of No. of 538 ant (5) s at SmokingCess 23.92 10.04 N/A N/A EU (43) classes No. of 24 2012 (17) participants The EU-15 23.35 9.89 N/A N/A o. of No. of 537 ati on 51 Chapter 5 52 Chapter 5 to thedailyconsumption offruitandvegetable by girls andboys aged11,13and15years. The following tableshows thetrends observed for Maltafrom theHBSCstudy withregards Source: Healthat aGlance, Europe 2012 vegetables stood at 51%. Maltese adultsconsuming fruitonadailybasiswas 74% whilst thedailyconsumption of According to theEuropean HealthInterview Survey (EHIS)for 2008,thepercentage of v. Source: HBSC2006,2010, Highlightsfrom thestudy onHealthBehaviour inSchoolChildren 2010 did notfare sowell where dailyconsumption ofvegetables isconcerned. that Maltese adultseat more fruitdailythantheaverage ofparticipating EUcountries, but vegetables (2008) Daily consumption of of fruit(2008) Daily consumption table 13|Co mp table 14|percentage ofchildrenreporting d 15 years 13 years 11 years Diet and Europeanault vegetable c B B B Girls Girls Girls oys oys oys arison offruitandvegetable c (17) 2002 The publication ofOECDHealthat aGlance, Europe 2012, shows 44 44 50 48 59 38 onsupti by genderinmalta,2002-2010 Females Males Females Males 2006 Fruit 46 34 42 33 35 47 s (33) 2010 40 43 42 25 41 41 onsumpti inMaltese Malta aily fruitand 43% 69% 78% 57% 2002 25 10 19 15 15 12 V egetables 2006 (33) (33) 14 14 19 12 8 7

EU-27 69% 59% 67% 57% (41) (41) 2010 23 16 16 18 15 21 (41) C. Incidenceofisea than that oftheEU-15 countries whichis6.8new casesper 100,000 population. than theEUincidence of11.54new casesper100,000 population, althoughitisslightlyhigher The incidence ofTBinMaltastood at 9.1 new casesper100,000 population in2012. This islower i. Communicable diseases:specialfocus onKoch (TB)andHepatitis B whole inbotheconomic andsocialterms. system. Additionally, theresulting absences from work significantlyimpactthe country asa The cost ofmanagementandtreatment ofdiseases places asignificantburden onthehealth available, how they taste, andwhy they are sobeneficial for thedevelopment ofhealthy bodies. and endeavors to create awareness amongst children asto what typesoffruitandvegetables are children, between theagesof3to 10years, aportionoffruitorvegetables at schoolonce aweek Scheme whichwas launched inMalta2010. This isanEUco-funded project that offers alleligible The HealthPromotion Unitforms partofanInter-Ministerial Committee that runstheSchoolFruit Coronary heartdisease and1%from cerebrovascular disease. 3% ofthesamplepopulation surveyed suffered from Myocardial Infarction, 3%suffered from Self-reported lifestyle prevalence intheEuropean HealthInterview Survey 2008showed that Source: European Healthfor Alldatabase, WHO number intheEU-27 countries was 1409.61 andtheEU-15 countries stood at 1263. number ofhospitaldischarges per100,000 population inMaltafor 2009was 984.56whilst the countries, ascanbeseeninTable 15below. Similarly, where respiratory diseasesare concerned, the Malta haslower discharge rates per100,000 population whencompared to theEU-27 andEU-15 Data onhospitaldischarges for ischaemicheartdiseaseandcerebrovascular diseasesshow that iii. Hospitaldischarges for ischaemicheartdisease, cerebrovascular diseasesandrespiratory system diseases estimate for Maltato the27 EUmemberstates, Maltaranks 8thhighest. International Diabetes Federation (IDF)for thesameyear (9.8%). When comparing theIDFnational aged 20to 79 years was 10.1%. (12)This isat parwiththenational prevalence estimated by the looking at themeasurement ofbloodglucose, theprevalence ofdiabetes amongst thepopulation The European HealthExamination Survey (EHES) pilotstudy carriedoutin2010 revealed that when ii. Diabetes population) andtheEU-15 countries (1.06 new casesper100,000 population). population (2011) islower thantheincidences inboththe EU (1.13 new casesper100,000 With regards to theincidence ofHepatitis Bthelocalfigure of 0.48 new caseper100,000 R C table 15|Comp Ischaemic heartdisease espiratory system diseases erebrovascular diseases in Malta andEU EU-15 c cerebro arison ofhospital dischargefor ischaemicheart disea se va scular diea se andrespirat ountries (per100,000 population) 984.56 350.25 106.52 Malta (17) ory s

y 1409.61 386.74 610.49 s (46) tem disea EU (5) (5) (5) in 2009 se in2009 1263.64 349.39 572.09 EU-15 (5) e, se,

53 Chapter 5 54 Chapter 5 cases per100,000 population (EU-25). 2006 -334.36new casesper100,000 population (Malta)whencompared to 325.50new incidence rate for Maltese females in2010 was slightlyhigherthantheEU-25rate for of 463.00 new casesper100,000 population. Ontheotherhandage-standardised per 100,000 population. This was slightlylower thantherate for theEU-25for 2006 all cancers (excluding non-melanomaskincancers) inmen,Malta,2010, was 395.39 The age-standardised incidence rate (European Standard Population) for new casesof iv. 8.4% ofalldeaths registered in2012. death accounting for 46.8%ofalldeaths. Deaths dueto respiratory diseasesamounted to system, namelyischaemicheartdisease, stroke andheartfailure are theleadingcausesof The AnnualMortalityReport for 2012 notes that deaths dueto diseasesofthecirculatory of thesurvey population reported having suffered from amentaldisorder From information acquired duringtheEuropean HealthInterview Survey in2008,15% v. new casesinpersonsaged65years andolderwas 57% for thesametimeperiod. new cancer caseswere diagnosedinpersonsaged60years andover. The proportion of Incidence ofcancer riseswithincreasing age. Over thefive year period2007-2011,71% of cervical, lung,colorectal andprostate cancer intheMaltese population for 2010. Table 16below shows somemore information regarding allcancers aswell asbreast, OECD 2009publication Societyat aglance, a pointintheirlifetime. When compared to OECDmembercountries asreported inthe have experienced more thanoneoftheconditions listed, e.g. depression andanxietyat mental disorder at somepointintheirlife. This numberincludesrespondents whomay females over 35 years andincreasing to amaximumof13%inthe65-74 year agegroup. reported lifetime prevalence ofdepression islow intheyounger agegroups, risingto 7.2% in Again, women experienced ahigherrate thanmen(7.7% and5.4% respectively). The Out ofthewholestudy population, 6.6%reported alifetime experience ofchronic depression. over 75 years (14.1%). groups (12.2%compared with9.7%) anditincreases withage, beingmost frequent inthe Chronic anxietyissignificantlymore likely to affect womenthanmen,withinallage 12-month self-reported prevalence rate ofchronic anxiety. in theOECDpublication Societyat aGlance, Maltaisseento come infifthplace for the from 10.2% in2002. Again whencompared to the11reporting OECDmembercountries from chronic anxietyat somepointintheirlifetime was 7.8% in2008.This percentage fell Where chronic anxietyisconcerned thenumberofrespondents whoreported suffering lifetime and12 monthprevalence rates oftotal mentalhealthdisorders. MentalHealth Malignantneoplasms(cancer) (6) (47) (48) Maltahasoneofthelowest self-reported (17) –i.e. a ‡‡

Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania,Malta,Poland, Slovakia andSlovenia EU-25 area countries includethosewho formed partoftheEUbetween May 2004andDecember 31st, 2006:EU-15 countries + Note: Source: MaltaNational Cancer Registry, Department ofHealth,Ministry for Health,2012

Age-standardised mortality rate Age-standardised incidence rate table 16|A a refers to rates for EU-25 C C Lung cancer All cancers Prostate cancer Female breast cancer C Lung cancer All cancers C Female breast cancer Prostate cancer olorectal cancer ervical cancer ervical cancer olorectal cancer cancers (uingEuropeanStand and EU-25c mortality rates per100,000 for theMaltese populati on for 2010 ge-s tand ‡‡ ardise inciencerates per100,000 andage-s in2002 ountries for 2006for allcancersando Females World Standard Population World Standard Population Males Females Males Females Males Males Females Females Males Females Males Females Males Females Females Females Males ard Population) New casesper100,000 population Malta (2010) Deaths per100,000 population 334.36 395.39 127.66 118.64 49.49 184.21 49.26 28.49 25.82 61.86 15.59 17.60 24.31 12.63 0.66 11.96 4.98 83.11 (47) ther selected tand EU-25 (2006) 463.00 236.40 325.50 136.20 110.30 10.50 59.00 62.40 25.00 35.60 26.50 23.20 18.40 15.60 ardise 106.2 3.70 21.70 17.80 a a

55 Chapter 5 56 Chapter 5 §§ 5.3 EU-20area countries are: Portugal, Italy, Sweden, Germany, Netherlands, Hungary, Denmark,Czech Republic, Slovenia, France, Ireland, Spain,Belgium,Austria, Poland, U.K, Finland,Malta, Latvia, Slovak Republic

A. services A ccess were lower thaninthe participating EU-15 MemberStates. of diabetes –admissions withcomplications were higherbutthosewithoutcomplications those for chronic obstructive pulmonarydisease(COPD) are lower inMalta.Inthecase per 100,000 for asthma are higherinMaltathanthosefor theEU-20 care settingaswell astheaccessibility andavailability ofservices. The rates ofadmission Avoidable admissions are taken asindicators for thequalityofcare intheprimaryhealth questions ontheprovision ofinformal care orassistance. Health Interview Survey to beconducted in2014 willfor thefirst timeincludethree availability andfunctionsoftheinformal carers. However thenext round oftheEuropean care bedsinthepublicsector. At present there isnodata available withregards to the beds per100,000 population). There ispersistent fulloccupancy ofthelongterm in demand.InMaltathetotal numberofLTC bedsavailable asat 2012 was 4588(1093.7 Indicators concerning long-term care (LTC) are alsovery valid to monitoring changes vi. Utilisation ofLong-term Care in otherEUMemberStates. during thelast few years andto analyse thesituation whencompared to thesituation aim to portray therange ofservices available andaccessed by theMaltese population highly dynamicandconstantly evolving. The indicators demonstrated inthissection place inanenvironment inwhichthefieldsofhealth systems andservices are Improvements are constantly ongoingparticularlyregarding timeliness. This istaking healthcare package hasconsistently andsubstantially continued to expand over time. different services, medicinesandmedical technologies. Consequently, thenational in Maltawithregards to theavailability ofandaccess to anincreasing range of Over thepast two decades,substantial progress hasbeenmadeinthehealthsector C Asthma -per100,000 population aged15+ A table 17|A v OPD -per100,000 population aged15+ voidable A oid able admission s , availability timeliness and of dmissions PULMONARY DISEA v medical and technologies, medicines oid able admission s: As

SE ( C OPD) inMalta an d EUc thma andCHRONICBS (33)

Malta 135 79 ountries –2009 §§ countries, TRUCTIVE

EU-20 184 53 (33) while (33)

C. Sec B. Medicaltechnol of clinicaldepartmentsandfor awiderange ofpathologies andincludedpatients ofallages. abroad system) in2012 totaled 415 (and608episodes). Referrals were sentfrom awidevariety categories. The numberofpatients referred for treatment abroad (through thetreatment Source: OECD, Healthat aGlance, Europe 2012 Note: *2010 figures; **Estimated figures Source: EUROSTAT Statistical Database Source: OECD, Healthat aGlance, Europe 2012 to 47,902. The total numberofprocedures carriedoutintheacute publichospitalsin2012, amounted situation invarious countries: where MagneticResonance Imaging(MRI)unitsare concerned. The tablebelow compares the selected countries (inthesouthernEuropean Region andtheUK).The samecannotbesaid Tomography (PET)scannersper1,000 population for theyear 2011 whencompared to Malta hadoneofthehighest numbersofComputed Tomography (CT) andPositron Emission Malta UK** Greece* C A table 18| Slovenia Italy C table 19|ItemsoffunctioningDiagnos Without complications: With complications: Diabetes –per100,000 population aged15+ yprus voidable A ountry ond ary Care (49)

A These includemajorvariant, intermediate andminorprocedures/operation c scanner, PET dmissions c v ountries per100,000 population for theyear2010 omplications –2009 oid able admissions: Diabetewithandut ogy CT Scanners 0.9 3.4 2.9 3.2 3.2 1.4 , Radiation therap (33) MRI Units 0.0 0.6 0.5 2.0 2.4 2.3 tic Imaging Technol y equipment)inMalta an d selecte PET scanners 0.0 0.0 0.2 0.2 0.1 - Malta 119 ogies (MRIunit 41 - (40)

E Radiation quipment T herapy 0.6 0.6 0.5 0.5 0.7 EU-15 1.0 109 50 s, CT -

(50) 57 Chapter 5 58 Chapter 5 * SirPaul Boffa HospitalisasmallhospitalnearValletta whichfor many years hasbeenproviding oncology, specialist palliative*** and dermatology care E. Community services for theelderly Unmetneed D. F. Onc Source: EUROSTAT (EU-Statistics onIncome andLivingConditions [EU-SILC] instrument) whole group and24% by thoseagedabove 85years). persons aged85years andolder. The service that was usedthemost was homehelp(7%by the 7.4% inthe60-74 year agegroup, rose to 20.7% inthe 75-84 year group andreached 24% inthe of care services was noted to risewithincreasing age. The overall take upoftheseservices was above community care services duringthe12monthperiodpriorto theinterview. The rate ofuse the elderlypopulation. Only11%oftheelderlypopulation recall makinguseofat least oneofthe 2008 European HealthInterview Survey reported that useoftheseservices was rather low within Care Help, Telecare, MealsonWheels, HandymanService andIncontinence Service. However, the There are alsoanumberofservices to supporttheelderlywithincommunity suchasHome list) for peoplelivinginMalta (2008-2011). examination for reasons ofbarriersaccess (expensive ortoo far to travel orwaiting (SILC) studies show alower thantheaverage EUself-reported unmetneedsfor medical care for financial reasons. However, the Statistics onIncome andLiving Conditions There are nonational surveys askingpeoplespecificallyonwhetherthey have foregone process ofintroducing several new clinicalservices at the Gozo General Hospital. the operating theatres andradiology departmentinGozo General Hospitalandisinthe investing withtheassistance ofEUStructural Fundsto purchase new equipmentfor that residents ofGozo have better access to care closerto home, theGovernment is issue for Maltadueto itssize andproximity ofservice provision. Nevertheless, to ensure The inabilityto access healthservices for geographic reasons isnotperceived asamajor and receives a fixed annualgrant from government. volunteers aswell asprofessional salariedstaff suchasnurses,social workers anddoctors cancer, motor neurone diseaseandotherterminal diseases. The organisation isreliant on that provides day andcommunity palliative care services to patients suffering from 10 bedsfor children andadolescents. Hospice Maltaisthelocalvoluntary organisation end 2014. The centre willhave 74 in-patient beds,including16beds for palliative care and has already beendoneanditisenvisaged that thisnew facility willbecome functionalby of oncology services from SirPaul Boffa Hospital***to Mater Dei Hospital.Extensive work A new oncology centre iscurrently being builtwhichwillleadto theeventual migration Malta EU countries table 20|Self-reporte d unmetneeds for medicalexamination for ol ogy services w c rea ountries: rea aiting lis sons ofbarrieraccess inMalta andEuropeanUnion 2008 0.7 t (%) 3.1 son beingt (18) (18) 2009 3.0 1.3 oo expensive,t (17)

2010 1.6 3.1 oo f ar t o travel or 2011 3.4 1.0

5.4

A. Trainedhealth careworkforce Q international implementation protocols of and consistency and continuity care of in anumberofhealthcare professions inMaltaandtheEUcountries for theyear 2010. The following tablecompares thenumberofstudents per100,000 population whograduated other professionals involved insocialcare. closely interact withprofessionals from othersectors suchaspsychologists, socialworkers and representatives from thedifferent relevant healthcare professional groups andfrequently on theincrease. Healthworkers often work inmulti-disciplinaryteams whichinclude expanding. Additionally, therange ofspecializations andsub-specializations is alsoconstantly groups. The range ofavailable alliedhealthprofessionals isvery wideandiscontinuously It ispertinentto note that thehealthcare workforce includesseveral professional andtechnical ongoing andare easilyavailable to allprofessionals. gain furthertraining experience overseas. Continued professional development programmes are programmes for theirtrainees whichare alsocoupled andsupplemented withopportunitiesto both locallyandabroad. Most ofthemedicalandsurgical specialitieshave structured training encouraged andprovided withopportunitiesto furthertheirexpertise intheirchosenfield This includestherecruitment ofwell-trained andqualifiedhealthcare professionals whoare activity insomeoftheaspectsthat contribute towards thissector. of thecare given by healthservices. The following sub-sectionswillillustrate performance and The healthsystem inMaltaiscontinuously working towards providing andimproving thequality per 100,000 population intheEU-15 in2011. average stood at 835.91 practising nursesper100,000 population and868.35 practising nurses there were 709.97 practising nursesper100,000 population in2011. Ontheotherhand EU practising nursesthelocalnumbers are still substantially lower thantheEUaverage. InMalta population andtheEU-15 of368.19 physicians per100,000 population for 2011. With regards to than theaverage rate intheEUaverage that stood at 345.80practising physicians per100,000 In 2011 there were 324.31 practising physicians per100,000 population inMalta.This islower Source: European Healthfor Alldatabase, WHO uality including care of patient safety Physicians Graduates table 21|Numberofs Nurses Pharmacists Dentists year 2011 health careprof essions inMalta andtheEUc (5) guidelines tudent s per100,000 population whgraduated inthe (5) Malta 17.08 22.61 8.90 1.68

/ or ountries for the , 10.64 36.18 3.93 2.67 EU , 59 Chapter 5 60 Chapter 5 B. National CancerScreeningPrgrammes C. V data from thissector may becaptured. respect to data for Maltaassomechildren are vaccinated intheprivate sector andnotall Source: European Health for Alldatabase, WHO a trend ofincrease uptake ofcervical smeartests withincreasing educational level. 61% reported having hadacervical smearintheprevious year. Itwas noted that there was reflects a rather highlevel ofopportunistic screening activity. Inthe25-34 year agegroup women reported having hadacervical smeartest at least once intheirlifetime. This reported data from theEuropean HealthInterview Survey 2008showed that 63.4% of A screening programme for cervical cancer isplannedto start in2015. However self- cancer screening isvery low intheMaltese population. in the60-69 agegroup. This shows that opportunistic screening activityfor colorectal their lifetime. This proportion increased slowly withincreasing ageandpeaked at 8.5% that only4.7% ofallrespondents reported having hadanFOB test doneat least once in faecal occult bloodtesting (FOBT). The European HealthInterview Survey 2008showed programme willbeinviting personsbetween 60to 64years ofageevery 2years for A national colorectal cancer screening programme was launchedinlate 2012. This resulting inaresponse rate of60.9%. During 2012, outofthe10,851 women invited to attend, 6,610 accepted theinvitation programme istargeting women aged50-60years andisinviting women every 3years. 2009 withtheintroduction ofthenational breast cancer screening programme. This Organised national screening programmes for selected cancers have beeninitiated since the EUaverage reached 85.9% in2011. eligible population. Hepatitis Bvaccination take uprate was 92.7% inMaltafor 2012 while Vaccine coverage for DTP, poliomyelitis andHibinMalta2011 reached 98.7% ofthe programme isinviting 12year old girls. for vaccination against HumanPapilloma Virus started to beimplemented in2013. This (MMR). Tuberculosis (BCG) isonlygiven to high riskchildren. Anational programme poliomyelitis, Haemophilusinfluenza(HiB),Hepatitis B,andMeasles,Mumps Rubella age. The scheduleincludesvaccines for diphtheria,tetanus andpertussis (DTP) and All children borninMaltaare entitledto free vaccinations untilthey are 16years of Poliomyelitis Haemophilus InfluenzaB(i) Measles Hepatitis B Diphtheria, T V table 22|V accination accine etanus, Pertussis (D accination c o verage inchildren2011 TP) (51) (5)

There may beadegree ofunderreporting with Malta 98.7 98.7 98.7 92.7 92.7 (17) (5) EU-27 96.0 93.9 85.9 96.7 96.1 (17)

5.5

D. Hosp italD. Stay andReamissions sustainability health our of system T needhe for along term vision for the medicine specialitywhere itstood at 9.4% admission. The findingsshowed that theemergency readmission rate was highest inthe unplanned readmissions within28days ofdischarge to thesamespecialityasprevious 2011. The definitionadopted to calculate the readmission rate was set at includingemergency/ An internal report onEmergency Readmissions to Mater DeiHospitalanalysed discharges in be aware ofthedefinitionbeingusedwhen comparing withotherspecialitiesorhospitals. Re-admission rates are often usedashospitalcare performance indicators althoughoneshould indicators are regularly monitored. important that, inorder to ensure that afree healthsystem remains sustainable certain expenditure onhealthisenormousandconsistently risingfrom year to year. Itistherefore and constant investment innew medicines,procedures andtechnologies meansthat the mentioned inprevious sections,factors suchasanageingpopulation, increased services The Maltese national healthsystems offers afree service for allpeople residing inMalta.As Source: European Healthfor Alldatabase, WHO lower thantheEUaverage of6.4days andtheEU-15 average of6.5days inthe2011. The average acute lengthofstay inMaltafor acute care hospitalsin2011 was –6.3days whichis 10 a Figure 2| 4 6 8 2

1990 c verage acute length ofs ountries –1990-2010

1995 (5)

2000 tay inMalta, EUando Greece

2005 Cyprus Israel S Italy ther European

20010 EU Slovenia Spain Malta (5) 61 Chapter 5 62 Chapter 5 comprise licensed**** Hospitals establishments primarily engagedinproviding medical,diagnostic andtreatment services that outpatient andhome healthcare services assecondary activities. the provision process. Although theprincipalactivityisprovision ofinpatient medicalcare they may alsoprovide day care, professional knowledge aswell asadvanced medicaltechnology andequipment,which form asignificantandintegral partof inpatients. Hospitals provide inpatient healthservices, many of whichcanbedelivered only by usingspecialized facilities and include physician, nursing,andotherhealthservices to inpatients andthespecialized accommodation services required by which stood at 9.6%. Product (GDP) for 2012, was 9.1%. (16)This isslightlylower thanthe2011 EUaverage The total expenditure onhealthinMalta,asapercentage of theGross Domestic €63.3 millionbeingpublicexpenditure onpharmaceutical products in2011. million in2011, with€99.2 millionbeingprivate expenditure onpharmaceutical products and products. There was anincrease intotal expenditure onpharmaceutical products from €162.5 pharmaceutical products whilst €71.7 millionwas public expenditure on pharmaceutical products in2012 was millionwas €173.9 million.Ofthis€102.2 private expenditure on charge to entitledpatients andthere isnoco-payment. Total expenditure onpharmaceutical public sector themedicines listed ontheGovernment Formulary List are given free of In theprivate system patients have to pay thefullprice for pharmaceuticals whilein the Note: The increase inhealthexpenditure seenin2005coincides withtheconstruction ofthenew Mater DeiHospital Source: National HealthAccounts, WHO beds per100,000 population. per 100,000 population. This isstill lower thantheaverage EUfigure for 2011, of542.05 as at endof2012. The total numberofhospitalbedsinMalta,2012, was 478.42 beds There are five publichospitals****(2acute and3specialised)three private hospitals both publicandprivate expenditure aswell asvoluntary healthinsurance. The following tableshows trends onexpenditure onhealthover 15years andincludes as %ofprivate expenditure onhealth Out ofpocket payments as %oftotal government spending Government healthspending Expenditure table 23|Trends inHealth ExpenditureinMalta, 1995 t as %ofprivate expenditure onhealth V as %oftotal expenditure onhealth V as %oftotal expenditure onhealth Private expenditure onhealth as %oftotal expenditure onhealth expenditurePublic onhealth as %ofGDP T (1995 prices) Purchasing Power Parity percapita T otal healthexpenditure otal healthexpenditure (€) oluntary HealthInsurance oluntary HealthInsurance (5) (5)

875.5 (60) 1995 95.8 32.5 67.5 9.9 5.6 4.1 1.3 2000 1248.1 96.9 72.5 27.5 0.8 6.6 12.1 3.1 o 2010 1964.8 2005 68.7 14.4 91.8 31.3 5.5 9.1 1.7 (16) 2319.8 2010 64.3 93.3 35.7 13.0 6.3 8.5 2.3

5.6 H and improving theservice hoursat Mater DeiHospital(e.g. having afternoon clinicsandlists). waiting lists, ensuringappropriate referral ofpatients, better managementofappointment times policy on healthsystem financing,apolicy on waiting times– this would tacklehaving centralised There are, however, anumber of policiesandstrategies whichare still pending.These includea and othersignificantmilestones: finalised andimplemented. The following isalist ofthepoliciesand strategies currently inuse Over thepast few years anumberofpoliciesandstrategies relating to Healthhave been ealth P • • 2014 • Settingupthestructures (includingtheNational Contact Point) for cross border healthcare. • HealthAct, 2013; • LaunchoftheHumanPapilloma Virus (HPV) vaccination programme; 2013 • Launchofnational colorectal cancer screening programme. • MentalHealthAct, 2012; • Embryo Protection Bill,2012; 2012 • SettingupoftheCommissioners for Health,for MentalHealthandfor Elderly Persons. • Outsourcing ofclinicalservices; • Restructuring to decentralise service provision; • Sexual HealthStrategy; • National Cancer Plan2011-2015; 2011 • Sexual HealthPolicy. • Non-communicable DiseaseStrategy; • Establishment ofFaculty for HealthSciences withintheUniversity ofMalta; 2010 • Consultation onaprimaryhealthcare reform. • Launchofthenational breast cancer screening programme; 2009 • SettingupofFoundation Programme andPost Graduate Medicaltraining centre. • Commissioning institutional care for theelderlyfrom private providers; • Pharmaceutical policy reform; • Introduction ofthePharmacy ofYour Choice Scheme(POYC); 2008 • Implementation ofnew ITsystems. • Commissioning ofthenew Mater Deihospitalandmigration to thenew hospital; • Collective agreements withthehealthcare unions; • Restructuring to separate Regulatory andService Provider Functions; 2007

Launch Launch

of of

theFood andNutrition Policy and Action Plan2014-2020; the National HealthSystems Strategy for Malta2014-2020. olicies &S trategies

63 Chapter 5 64 Chapter 5 services needto beconstantly reviewed andaugmented. elderly, however dueto anincreasingly ageingpopulation andincreasing demands,these As hasbeenmentionedpreviously there are already many services inplace for the and furtherdevelop therange ofcommunity services for theelderlyisbeingdeveloped. developed. Inthesector concerned withthecare ofelderlypatients, aplan to enhance A national planfor rare diseasesandanational diabetes strategy are alsobeing and anational policy for children. dealing withthereduction ofpoverty andsocialinclusion,theabuseofdrugsalcohol a national strategy for active ageing,andisalsoresponsible for policiesandstrategies and SocialSolidarity(MFSS). Additionally, MFSS publishedandstarted to implement A strategy for dementiahasbeenlaunchedfor consultation by theMinistry for theFamily (The people-centred(The approach) systems health of the P Chapter 6 6.1 I eople at the heart heart the at eople ntroduction enter aclinicalhealthcare sector orfacility. and itaimsto reach peoplein thegeneral community longbefore they become patients and interactions aswell aspublichealthinterventions, inparticularprevention andhealthpromotion, and stakeholders ofthehealthcare system. Itrecognises and addresses bothhealthcare expectations, preferences, capacities,andhealthwell-being ofalltheconstituents The people-centred approach involves abalanced consideration ofthevalues, needs, implementing thestrategic actionsthat are documented intheNHSS. and relevant structure andthat itistherefore more suitablefor thetaskofplanningfor and visible healthcare systems itwas felt that thepeople-centred approach isamore appropriate of aoverarching healthsystem rather thanjust concentrating ononlythemore familiar and and protecting theirown health. that before peoplebecome patients they needto beinformed andempowered inpromoting distinct from themore commonly portrayed patient-centred approach becauseitrecognises A people-centred approach meets these broader challenges.Apeople-centred approach is quality andholistic healthcare, itdoesnotmeetsomeofthebroader healthchallenges. providers andtheirexperiences in theclinicalsetting.While thisapproach addresses issues of The patient-centred approach primarilyfocused onpatients, theirinteractions withhealthcare is viewed andrespected asawholepersonwithmulti-dimensionalneeds. adopt amore humanistic andholistic approach to healthcare, where theindividualwhoneedscare health care organizations andhealthpractitioners to move to ahigherlevel ofperformance and people canaspire to higherexpectations from thehealthsystem. They now expect healthsystems, countries suchasMalta,where basichealthinfrastructure andessential healthservices are inplace, of allhealthcare stakeholders andsectors hasbeengainingininterest over thelast few years. In The patient’s perspective ofhealthcare andhow healthsystems canbetter respond to theneeds capacities ofallhealthconstituents andstakeholders. care, andabalanced consideration oftherightsandneedsaswell astheresponsibilities and all stakeholders involved. This entailsamore holistic approach to healthsystems andhealth being ofallthememberspopulation anditmust encompass thebroader context, with in national healthisbasedonthecore value ofprotecting anddeveloping healthandwell- sustainability ofthehealthsystem are importantandpressing issues. Policy development environmental factors. Access, patient safety, qualityandresponsiveness ofcare andthe Health isinfluenced by a complex interplay ofphysical, social,economic, cultural and (52) Since thisstrategy isencompassing thebroader view

65 Chapter 6 66 Chapter 6 as theultimate enablerfor change. mutually reinforce eachotherandleadershipwithinacross alldomainsisaccredited To achieve any real transformation inany partofthehealthsystem thesedomainsmust HEALTH authorities HEALTH careorganisations HEALTH practitioners groups orpolicy andactiondomainsincludethefollowing: groups work for andare concerned withthesuccess ofthehealthsystem. These four The people-centred approach recognises four majorgroups ofstakeholders. Allthese improvements inthequalityandresponsiveness ofthehealthsystem. also beconsidered andthey alsoshouldbeempowered to beableto transform anddrive the families andcommunities that thehealthsystem isdesignedto serve. Their needsmust other membersofthegeneral population. They may become patients andthey form partof are alsopeopleandthey have needsandexpectations from thehealthsystem like allthe are delivered. Healthcare professionals, healthservice managersandhealthpolicy-makers provide theservices andwhoruntheorganizations andsystems withinwhichhealthservices not just thosewhodemandandneedsupportto achieve goodhealthbutalsothosewho Furthermore, thepeople-centred concept hasanadditionalutilityinthat itencompasses 2007 (page28;Table 2) Source: Adapted from People at thecentre ofhealthcare: harmonizingmindandbody, peopleandsystems, Domain table 24 |Differentplayers withinthe4keypolicy andaction Health Organizations Health A Health Practitioners and C Individuals, Families ommunities individuals, families andcommunities uthorities domains inthepeople-centredhealth s Varies dependingonmodel patient advocacy groups, Clinicians andclinical Clinicians andclinical Patients andfamilies, patient associations Clinical setting of healthcare support staff support staff Communities andpopulations Community healthcentres y Voluntary Organizations Public healthfacilitiesPublic Public healthworkersPublic Public Healthsetting Public s Public healthsectorPublic Prevention workers Ministry for Health tem appro Local government ach (52) 6.2

The individuals, communities, professionals, organisations andpolicy-makers clinical medicineaswell aspublichealthandincorporates theentire spectrumofhealth care: This initiative introduced theconcept that people-centred healthcare isconcerned withboth working to reduce theburden ofchronic conditions. policy environment that organizes thevalues, principlesand general strategies ofgovernments for chronic conditions. Moreover, theframework recognizes theimportance ofasupportive and communities are encouraged to connect withhealthcare organizations inproviding care framework patients andtheirfamilies were positionedat thecentre ofthehealthcare system, health care. Through thedevelopment oftheInnovative Care for Chronic Conditions (ICCC) by today’s healthcare systems, particularlyinrelation to puttingpeopleat thecentre of The WHOhasissued several studies andreports addressing theissues andchallengesfaced promoting healing. understanding ofthepatient’s complaints, basedonpatient-centred thinking,was importantin arise from emotionalstress andnotphysical causesandthey recommended that athorough as “illness-centred medicine”.Intheirview, aconsiderable proportion ofpatient complaints colleagues asanalternative approach to traditional medicalpractice, whichthey portrayed The term “patient-centred” medicinewas first mentionedin1970 by DrMichaelBalintandhis are alsovalid for thebroader concept ofpeople-centeredness. acknowledge that several oftheelementsidentifiedasintegral to thepatient-centred approach health care andare essentially variations ofpatient-centred care. Nevertheless, itisimportantto characteristics. The majorityoftheseframeworks still focus mainlyontheclinicalexperience of existing modelsintheliterature andsomeofthemattempt to delineate itspredominant The ideaofpeople-centred care isafairly new concept andisstill developing. There are several prevention andcommunity healthpromotion inhealthcare. inherent limitations ofthephrase “patient-centred”, acknowledging thecritical role for In its2005publication theInternational Alliance ofPatients’ Organizations recognized the dynamic inter-relationships between thevarious stakeholders inhealthcare. requires the healthsystem to move towards ahigherlevel offunctioningandemphasized the coverage for thishealthcare. Heasserted that thechangingnature ofhealthandcare provide allitscitizens withaccess to auniversal level ofhealthcare andto provide thefinancial arguing that thecurrent Canadianhealthsystem hadalready metitstwo initialgoals,namely, to Dr Vaughan Glover in2005.Inthispublication heproposes ahealthcare reform for Canada The term “people-centred healthsystem” madeitsfirst appearance inabookpublished by is safe, effective, patient-centred, timely, efficientandequitable. operating withinasupportive payment andregulatory environment to produce healthcare that centred teams andorganizations that facilitate thework ofotherpatient-centred teams systems standpoint. IntheIOMmodel,care system isinclusive ofhigh-performing patient- patients andtheirfamilies, andintroduced theconcept ofpatient-centred care from ahealth System for the21st Century. This work moved aheadfrom theearliermodelsthat focused on In 2001, theInstitute ofMedicine(IOM)publishedCrossing theQualityChasm:ANew Health of patient-centeredness andextending itto involve thepatients’ families. Institute andtheInstitute ofHealthcare Improvement (IHI)continued to develop ontheconcept Other authorsandacademicprofessional institutions suchasLevenstein, thePicker Pacific andSouth-East Asia Regions inthe work titled People at the Centre ofCare Initiative. “patient-centred” to “people-centred” healthcare was first articulated by theWHO Western evolving (53) concept of people (55) - (57) centred Finally, the fulltransition from (54)

approach (56) (58)

67 Chapter 6 68 Chapter 6 ††† 6.3 Western Pacific. People at the centre ofhealthcare: harmonizingmindand body, peopleand systems, 2007 (pages 35-39) The text ofthissub-section hasbeenadapted from WHORegional Office for South-East AsiaandWHO RegionalOffice the for

a

T A. Indiviuals, f B. Health practitioners valueshe values have beenexpressed inseveral WHOandotherinternational documentsandinclude: Patient- andpeople-centred care share several core values andguidingprinciples.The core development ofthefollowing key characteristics by policy andactiondomains. Evidence from research, practice andevaluation ofhealthsystems hasledto the centred care is: These core values have beendeveloped into anumberofessential principles.People- people 4. 3. 2. 1. Respect for patients, theirneedsanddecisionsat theclinicallevel andrespect for • Holistic approach to thedelivery ofhealthcare • Supported involvement inhealthcare decision-making,includinghealthpolicy, • Personal skillswhich allow control over healthandengagementwithcare • Access to clear, concise andintelligible healthinformation andeducation that • Equitable access to healthsystems, effective treatments andpsychosocial support • ethicalandfosters transparency andaccountability. • efficient,coordinated andprovided inatimelymanner • evidence-based and compassionate • effective, leadsto better healthoutcomes • aboutenablingstakeholders to make theappropriate choices • concerned withtheengagementofallstakeholders • equitable • health anddevelopment. The importance ofparticipation andinclusionofindividualscommunities in An effective tool to endall forms ofdiscrimination The central role ofhealthinany process ofdevelopment andeconomic growth Respect for humanrights anddignity communities andtheir needsat thepopulation health level programme development, resource allocation andhealthfinancing. making, problem solvingandself-care systems—communication, mutualcollaboration andrespect, goal-setting,decision- increases healthliteracy andallows for informed decision-making - centred amilies andc , principles characteristics and of ommunities health system approach †††

D. C. Health careorganizations Health A Accountability. • Transparency • Involvement ofcommunities andother stakeholders inhealthgovernance and policy • Commitment to aprocess ofongoingevaluation andimprovement • Collaboration withlocalgovernments and communities andvoluntary organisations • Abilityto develop standards andprotocols, andto disseminate guidelinesandstandards • Investment inhealthprofessional education that promotes multi-disciplinaryteamwork, • Financingarrangements that ensure thesustainability ofthehealthsystem • Primarycare asthefoundation for better health • Service modelsthat recognize psychosocial dimensionsandsupportpartnershipbetween • Organization ofservices that provide convenience andcontinuity ofcare to patients • Avenues for grievances and complaints to beaddressed • Employment andremuneration conditions that supportteamwork towards people- • Acknowledgement oftheimportance ofallstaff—managerial, medical,alliedhealth, • Access to psychological andspiritualsupportduringthecare experience • Safe andwelcoming physical environment supportive ofdifferent lifestyles, family, privacy and • Commitment to quality, safety andethicalcare • Accessible to allpeopleneedinghealthcare • Involvement inhealthcare governance andpolicy decision-making. • Teamwork andcollaboration across disciplines,providing coordinated care andensuring • Commitment to quality, safe andethicalcare • Adherence to evidence-based guidelinesandprotocols • Access to professional development anddebriefingopportunities • Provision ofindividualized care at theclinicalsetting • Professional skillsto meettheseneeds—competence, communication, mutualcollaboration • development for goodpractice about psychosocial dimensionsofhealthcare good communication skills,anorientation towards prevention, andintegrates evidence individuals, theirfamilies andhealthpractitioners. centred healthcare ancillary—in thedelivery ofhealthcare continuity ofcare and respect, empathy, healthpromotion, diseaseprevention, responsiveness andsensitivity dignity uthorities

69 Chapter 6 70 Chapter 6 objectives andstrategic directions ofthisstrategy. are documented inthefollowing sub-chapters dealingwiththeindividualoverall these concepts willberepeatedly evident isseveral ofthestrategic actionsthat for Healthhasfor thefuture development ofthenational healthsystems and and content oftheNHSS. They are inlinewiththevisionthat theMinistry responsible The above values, principlesandcharacteristics are allvery relevant to thestructure Objectives, Directions and Measures Objectives, Measures Directions and H N people-centred I Chapter 7 7.1 mplementation of of mplementation

ealth Systems:ealth THROUGHOUT LIFE OVERALL OBJECTIVE 1–HEALTH W AND The mainthrusts willinclude: Indiviuals, f community andasnearpossible to where people are residing andworking. encouraging communities to become more involved intheprovision ofinformal care inthe all settingsproviding healthservices andthere willbeincreased focus onempowering and the personat different stages ofthelife course. Actions need to betaken to continue upgrading suitable to theneedsandisconducive to sustaining andimproving thehealthandwell-being of Action willbetaken to ensure that thecare required isdelivered inthesettingwhichismost dependency care. Prolonging stay inthecommunity andresponding to increasing demandsfor higher THE RIGHTCAREAT THERIGHTPLACE ANDAT THERIGHTTIME Strategic Direction 1A groups. epidemiological trends focusing onthewholecourse oflife, children, theelderlyandvulnerable To respond to increasing demandandchallengesposedby thedemographic changesand 1. the healthsystem. Actions willincorporate activitiesto: individuals, families andcommunities abouttheirrightsfor andresponsibilities towards The dissemination ofconsistent information andeducation to raise theawareness of a. services, medicines andmedicaldevices. continue sensitising thepubliconresponsible useandconsumption ofhealthcare amilies andc ommunities

ational ell

- being 71 Chapter 7 72 Chapter 7 3. 2. necessitating specialattention inmost health-related strategies include: specific anddistinctive requirements. Vulnerable groups that haveas beenidentified implement actionsaimedpurposelyat identifyinginmore detailandaddressing their Policies andstrategies willcontinue to identifyvulnerable groups and designand services. This willbeachieved through voluntary organisations andpatients andresidents groups inprovision ofhealth The strengthening oftheimportance oftheroles ofthelocalgovernment, i. people at highriskofoccupational ill-healthandsafety; h. peopleat higherriskoforwithmentalhealthproblems; g. frail olderpersonsandsuffering from dementia; f. peoplewithrare conditions anddiseases; e. peoplewithphysical andintellectual disabilities; d. people withaddictive behaviour difficulties; c. Migrants, asylum seekers andforeign workers;b. a. c. b. a. f. planfor thesettingupofacentralized information service that willbeableto e. d. c. b. of thissister island. residing inGozo especiallythose that are accentuated by thedoubleinsularity difficulties andneedsofthe patients andtheir familiesandthepopulation designed to increase theresponsiveness ofthehealthsystems to thespecial Special attention willbedevoted to Gozo. Inparticular, measures willbe parent households; people at-high-risk-of-poverty suchaslower socio-economic classes andsingle provision willbebrought more to theattention ofdecision-makers. this way theneedsofthisimportantgroup of partnersinthehealthcare service not onlyfor patients butalsofor theirmembercare providers andvolunteers. In increasing therole ofvoluntary organisations andpatient groups asadvocates decision-making processes at anational level further encouragement andsupportto helpincrease theirparticipation in further acknowledging theircontributions andfunctions available andthat are most suitableto theirneeds. will assist themto navigate thewiderange ofhealthandsocialcare services inform service usersandproviders withhighqualityandtimelyinformation that accountable for sustaining goodstandards inpublichealth. support changesinthemembersofpublicto collectively become more more responsible for themaintenance oftheirown well-being andhealth. availability ofdevices that willhelpindividualsachieve theircapacityto become facilitate thechangesneededandintroduce structures, services andthe informal carers orjoinnetworks ofinformal carers. encourage, educate andsupportindividualswhooptfor andperform therole of institutional care asfar aspossible. ultimate aimofthesemeasures willbeto helpavert anddelay theneed for long-term of theirown health,andthehealthofdependentsincludingelderlyrelatives. The support andencourage individualsandfamilies to beinvolved inthemanagement The mainthrusts willcomprise: Health careorgani s practitioners to thehealthandcare needsinthecommunity. This willbeachieved through: The mainthrust willbethrough initiatives to increase theawareness andsensitivityofhealth Health practiti oners 2. 1. 3. 2. 1.

facilities. care andreduce theneedfor admissions andlong-term hospitalisation inmentalhealth gate keeping andcoordinating roles and thecapacityfor outreach services ofprimaryhealth These actionswillalsoresult inimprovements intheearlyrecognition ofmentalill-health, to augmenttheircapacity to dealwiththeincreasing prevalence ofmentalhealth disorders. expanded. More training to healthcare professionals inthissector will beprovided inorder mental healthinfrastructure intheprimaryhealthcare andcommunity care sectors willbe patients backinto societyandprevent re-admission to hospital.To achieve thisaim,the living ininstitutional care (particularlyinmentalhealthfacilities) soasto reintegrate these The provision ofsustainable rehabilitative community services for suitablepatients currently through: The strengthening ofthemulti-disciplinaryapproach to patient care. This willbeachieved illness anddisability, community psychiatric care andpalliative andend-of-life care. areas that needparticularattention includethecare ofpatients withco-morbidities/ chronic the role ofthefamily doctor particularlyinareas where itisfelt ismost needed.Identified practitioners working inthecommunity. There willbeaspecialemphasisonstrengthening Promoting amulti-disciplinaryapproach to patient care andenhancingtherole ofhealth pharmacy anduseofinappropriate drugs professional development to update skillsto prevent sub-optimalprescriptions, poly- guidance shouldadmission to residential homesberequired. This willalsoincludecontinued elderly relatives anddependentpersonswithphysical anintellectual disabilitiesaswell as proficient inproviding assistance andinformation to peoplecaring for or residing with Educating andsupportingfamily doctors andotherhealthpractitioners to become more of-poverty especiallythechildren hailingfrom thesesocialstrata. issues for sexual healthandthemultiplecomplex healthissues ofpeopleat ahighrisk- identified asmeritingspecial attention includementalhealthissues intheelderly, access about therange ofservices provided andhow thesecanbeaccessed. Areas that have been Continuously updating healthpractitioners sothat they remain highlyknowledgeable c. b. a. care. Training andempowering primarycare andcommunity service providers inrehabilitation support. with anemphasisonpromotion, prevention, earlyintervention andcommunity both at inpatient and outpatient levels, to cater for different needsofthe community the provision ofcomplementary anddiversified multi-sectoral specialisedservices, facilitating information sharingfrom andto hospitalandcommunity care settings. ations

73 Chapter 7 74 Chapter 7 Several actionswillbeundertaken. These include: Health authorities 6. 5. 4. 3. 2. 1. requiring specialattention includeincreases inthecapacityofandavailability to: personnel andexpertise required to upgrade and introduce new services. Areas to cater for theconsequent increases orchangesinthe complement ofthehealth Increasing thecapacityofservices asandwhere needed.This willinvolve activities and intellectual disabilities. community care services otherthantheelderly, suchaspersonswithsevere physical Carrying outaneedsassessment for groups needinglong-term care andspecialized existing services. professionals andentitiesthat canevaluate the performance andeffectiveness of This willbeachieved through thesettingupofandincreased supportto more Consolidating thestructures that perform assessments onproposals for new services. areas: young people. These strategies willprovide for andfocus onthefollowing identified updating thestructures dedicated for thepromotion ofwell-being inchildren and Designing anational policy andstrategies aimedat expanding theresources and resort to theemergency andhospitalservices willbeplannedandimplemented . of crisis.Measures that willaimat providing supportfor carers to minimize theneedto involvement ofthepatient’s chosenrelative orcarer isimportant,especiallyat times Formally recognising andincreasing supportto informal care inthecommunity. The to choice andinvolvement inclinicaldecisionswillbegiven specialattention. provision ofinformation aboutthepatient’s condition andcare andthepatient’s right increase awareness ofpatients’ rightsandlegalobligations willbeimplemented. The Formalising patients’ rights intheMaltese legislation. Information campaignsto e. d. c. b. a. c. b. a.

health supportservices canbedelivered. community centres co-located withnursinghomesfrom whichcommunity can prolong independentliving. assistance for thepurchase orloanofassisting technologies that supportand respite care services. geriatric rehabilitation services, needs. long-term care facilities particularlyto cater for peoplewithhighdependency working withthesecohorts. Strengthening ofcollaboration withtheeducational andsocialservices term, over thecare that they receive ifotherwisethey are hospitalised. as for theirneeds for immediate care and prevention from harmintheshort- the long-term development andsocialinclusionoftheseyoung peopleaswell this unitissupported by scientific evidence that shows greater benefit forboth adolescents withchallengingbehaviour andspecialneeds.The development of the promotion ofpsychological, psychiatric andbehavioural care ofchildren and The creation ofanew suitableunitinthecommunity that willbededicated to psychological developmental difficulties. regards to healthpromotion, diseaseprevention andscreening for physical and The childhoodandadolescent agegroups willreceive specialemphasiswith as avalue initself’ economic resource isincreasingly becoming more prominent worldwide. The concept of‘health The linkbetween healthandeconomic prosperity andportraying healthasasocialand health andsafety risks,road traffic accidents, and accidents inthehome. consumption andharmfulintake ofalcohol anddrugs,environmental andoccupational key issues includingpoorandunbalanced nutrition,low levels ofphysical activity, tobacco to betaken to promote healthandprevent diseasethroughout thelife course by tackling actions to ensure andsafeguard food safety andconsumer protection. and conditions, actionto prevent accidents andinjuries,improving workers’ safety, and to emergencies, epidemics andbioterrorism, strategies to tackle riskfrom specificdiseases between policy measures, healthoutcomes, costs andbenefits,preparedness and response health threats. These includehealthimpactassessments to articulate therelationship to protect humanhealthandimprove safety, securityandprotection ofcitizens against This strategy alsoaffirmsthe continuation and consolidation ofinitiatives and resources in healthcare spendingdueto ageingcould besubstantially reduced. EU projections show that ifpeoplesucceed inremaining healthy asthey live longer, therise prevention ofdiseasethroughout thelife course andcontrol ofdiseaseprogression. and lifestyle choices includingprotection, screening andearlydiagnosisofhealthrisks, Strengthening theprevention andpromotion ofhealthfocusing onbehavioural changes ENGAGEMENT ANDEMPOWERMENT T Strategic Direction 1B level ofindependence. All theseservices shouldaimat sustaining andrestoring inparticularolderpersons’maximum supply, humancapitalandpublicspending. knowledge that people’s health influences economic outcomes in terms ofproductivity, labour 10. 9. 8. 7. follow instructions for treatment. understand and usehealthcare information to make appropriate healthdecisionsand members ofthepubliclearnnecessary skillsthat will empower themto obtain,read, Designandimplementprogrammes to increase healthliteracy inthepopulation sothat be given intheareas ofcancer andrare diseases. Continuing withthephasedexpansion oftheGovernment formulary. Specialattention will to effectively address theseimportantskillgaps. appropriate numberofsuitablepersonswillberegularly sentabroad for training inorder orthoptics, optometry andclinicalphysiology. Action willbetaken to ensure that an in thepathology sector andallied healthcare professionals inprosthetics andorthotics, local training courses. Examples includeprofessionals sub-specializinginseveral areas is essential for theservice, thenumberofprofessionals required istoo smallto justify Some ofthesegroups require specialattention becausealbeitthetypeofprofession continued professional development ofseveral highlyskilledhealthprofessional groups. Investing inthehealthsector necessitates investment inthetraining, recruitment and people withsevere mobilityproblems andpersonswithdisabilitywillbeplanned. A new programme that willaimat delivering medicinesto theresidences ofelderly f. for theplace ofdeath, ifpossible. her/him diewithdignityandinlineher/his requests, suchasregards thechoice patients. Every patient requiring end-of-life care needspalliative care supportto help address theneedfor palliative care services that cater for patients otherthancancer (28) andasaprecondition for economic prosperity alsopromotes thegrowing O PRM (29) TE HEALTH (38) Action willcontinue 75 Chapter 7 76 Chapter 7 medicine andhealthpromotion. Actions willbetaken to: practitioners to increase theirroles, involvement inandaccountability for preventive The maindrivingforce willincorporate increasing investment to supporthealth Health practitioners special attention given to thechildren, adolescents andyoung adults. Programmes willbetailored andaimedat identifiedsub-groups ofthepopulation and The mainthrusts include: Indiviuals, f 1. 3. 2. 1. (such asby genderand/or age) .They willbe: prevention, screening andearlydiagnosiscanbeaimedat different groups main function.These clinicswillhave anincreased focus onhealthpromotion, Establish clinics that willhave general andspecifiedhealthchecksastheir disease control. Specialattention willbegiven to: Increasing knowledge andunderstanding ofself-care such asself-monitoring for risk ofcontracting, protracting anddisseminating specific communicable diseases. aimed at identifiedsub-groups ofthepopulation that are considered to be at higher to unnecessary andunwarranted fear ofinfections. Programmes willbetailored and appropriate actionistaken whilst avoiding over-reaction andinappropriate actionsdue Educating thepublicaboutriskfactors for communicable diseasesensuring help prevent, theonsetofnon-communicable diseases.Initiatives willconcentrate on: Educating thepublicaboutriskfactors for developing, andthelifestyle choices that supported by andreceive continued professional development coordinated by • ledby community healthpractitioners withspecial interest andtraining in • basedin theprimaryhealthcare system, • multi-disciplinary, • d. c. b. hypertension a. diabetes c. b. a. the specialist unitsandservices inthesecondary healthcare. specific fields, maintaining goodoral health. encouraging regular andplanned healthchecks felt to beparticularlyimportantfor mentalhealthandsexual healthconditions. system at anearlystage for diagnostic investigation andcontrol ofdisease. This is persons withasuspicionofbeingaffected donot feel threatened to approach the reducing any existing stigma associated withcertain medicalconditions suchthat monitoring. the importance ofearlypresentation, compliance withtreatment andregular tackling thenational problems ofobesityandlackphysical exercise amilies andc ommunities

direction: A numberofinitiatives willspearheadactionby healthcare organisations for thisstrategic Health careorgani s be carriedout. An evaluation oftheHealthAwareness clinicsthat are already inoperation insometowns will are considered to beat ahigherriskorwithprobability ofpositive long-term outcomes. by invitation. The latter methodwillbeadopted to engagepersonsandgroups ofpeoplethat Attendance at theseclinicsmay befollowing areferral from ahealthpractitioner, self-referral or Actions willinclude: 2. 1. 5. 4. 3. 2. Concentrate efforts to: sugar andfats. sale andadvertisement oftobacco andtobacco products, alcohol andfood that ishighin otherwise). Carryoutconsultations andthedrafting andenactmentoflegislation onthe Launch andenforce total smoking bansinandaround allhealthfacilities (healthcare or consistent information andsupportto allmothers. breastfeeding) for healthprofessionals sothat they may transmit thebest possible and Provide educational programmes onmaternal andinfant nutrition(including with allsituations. order to develop askilledwork force that candealappropriately (ethically andhumanely) communication skillsandnon-discriminatory practices ofevery healthprofessional in Continue with initiatives to furtherdevelop theawareness, attitudes, information, indicated, theseprogrammes willalsoseekto: Update protocols for screening andsurveillance programmes asnecessary. Where seek theiradvice. that updated, timelyandconsistent advice isgiven to patients andotherpersons who provided andguidelinesfor healthcare professionals willbeestablished thusensuring other professional groups inprimarycare. Continued professional development willbe Implement specifichealthpromotion programmes that willbeled by family doctors and reduce theaverage systolic anddiastolic bloodpressure, andthelevel ofserumcholesterol in • regularly update andreview thelegislation concerned withnotification ofdiseasesand • step upenforcement ofnotification ofdiseases(particularlyinfectious diseases), • increase structures andresources for thesurveillance ofmore diseasesorgroups of • provide training incounselling at bothpre- andpost-testing phases, • target highriskgroups ofpeople, • a. increase theamountofphysical activityundertaken by allagegroups. • the notification processes including contact tracing andnotification ofpartner/s. diseases, professionals to thepublicsuchasonweight management. guidelines willbeissued to facilitate thedelivery ofconsistent messages from allhealth management ofpersonswith weight reduction andcontrol problems. Furthermore, the primaryhealthcare sector whichwillprovide aholistic approach to theoverall Specialised obesityclinicswillbesetupandrunonamulti-disciplinary basisin the general population ations

77 Chapter 7 78 Chapter 7 Action willfocus on: Health authorities 6. 5. 4. 3. 2. 1. 4. 3. governments andother stakeholders for the: through for example theprovision ofexpert advice to national andlocal the Ministry for Health.Examples ofsuchactivitywillinclude continued support Stepping uptheadvocacy for Healthwithinstitutions andfor initiatives beyond active andparticipative life. term complications thereby allowing personswithdiabetes to continue to live an and control andprevention andmanagementofdiabetes emergencies andlong- at increasing awareness for theprevention, earlydiagnosis,improved monitoring Design, launchandimplementacomprehensive National Diabetes Strategy aimed development assessment services inthesecondary healthcare sector between theprimarychildandyouth healthservices andthespecialist child surveillance pointsinchildren olderthan4years. Strengthen thecollaboration surveillance programmes to cover allschoolsinMaltaandto includeother Reinforcing theprimarychildandyouth healthservices. Expandchildhealth knowledge andskillsattitudes andbehaviour. impact andpositively encourages andsupportsindividuals’publicchangesin implementation ofwell plannedandeffective campaignsthat canleave an Utilising dedicated national, European orWorld days and timeperiodsfor the Develop andimplementprogrammes to educate andinform: programmes. Regular updates for theprovision andinvestment innational vaccination post-traumatic stress disorders. situations suchasmotor vehicle accidents, accidental deaths, victimsofcrimeand new expert groups that canaddress people’s reactions whenfaced by traumatic crises andtheSexual Assault Response Team (SART). Planfor theinception of Consolidate existing teams suchastheCrisisIntervention Team for psychiatric Increase thescope ofdifferent crisesintervention and rapid response teams. services according to theirneeds. trained cultural mediators to increase theiraccess andefficientuseofthehealth Provide culturally appropriate andmulti-lingualinformation for foreigners and a. d. c. b. a. b. of incentives to increase the useofthesefacilities. school grounds after schoolhoursfor organised sportsactivitiesandtheprovision activities suchasoutdoor gyms,parksandpedestrian areas andtheuseofpublic development ofpublicrecreational areas withfacilities that encourage physical control continence promotion, andprevention ofdehydration andbodytemperature on common age-related modifiableandpreventable crisessuchas falls prevention, the life course withspecialattention to vulnerable and marginalised socialgroups. on healthpromotion invarious settingsthat willaddress healthdeterminants across civil societyonhealthanditsdeterminants policy makers inallGovernment departmentsat thenational andlocallevel sector suchasqualifieddieticians,nutritionists anddental hygienists. Increase thenumberofcertain professional groups particularlyintheprimarycare 7.2

DYNAMIC HEALTH SYSTEMS OVERALL OBJECTIVE WITHIN EQUITY 2-ENSURING be accomplished through: partners withservice providers to improve theefficiency ofthe national health system. Thiswill Service userswillbesupported andencouraged to increase theirrole andinvolvement as Indiviuals, f the emergent fieldsofscientificenquiry. local andregional research, innovation andhighereducation inthehealthsector especiallyin promotion oftheestablishment ofstructures andinstitutions that willprovide for andpromote people-centred andevidence-informed andbased.Measures are alsoincludedfor the standards through healthsystems that becomes increasingly financiallyviable, fit forpurpose, achieving andmaintainingservices that assure highlevels ofsafety, qualityandefficiency migration, andmobilityofpatients andhealthprofessionals. Action willconcentrate on for theintroduction ofnew, more expensive andsophisticated technologies andmedicines, to thechallengespresented by anageingpopulation, risingcitizens’ expectations, demands The national healthsystems are underconstant andescalating pressure to actinresponse prioritisation, monitoring, public private partnership, andotherservice provision models. Improving managementandefficiency ofservices through research andinnovation, MAKING BES Strategic Direction 2A and healthtechnologies. Increase equitableaccess, availability andtimeliness ofhealthandsocialservices, medicines our roads safer andourenvironment cleaner. prevalence ofobesity, butthey willalsoreduce thenumberofvehicles ontheroad thusmaking Such initiatives willnotonlyincrease theuptake ofphysical activity, thuslowering the 3. 2. 1. communication to remind patients ofupcoming appointmentswillbeintroduced. Communication withpatients willbeincreased andtheuseofnew meansof Further educating thepublicto respect their appointmentdates and times. avoiding excessive waiting times. emergency for appropriate useoftheAccident andEmergency (A&E)departmentthus Educating andinforming thegeneral population onwhat constitutes agenuine going to theemergency department. level ofcare andto, where possible, seekadvice andconsult theirfamily doctor priorto primary healthcare system whentheirproblem canbeappropriately addressed at this health system. Specialfocus willbeconcentrated oneducating thepublicto resort to the Disseminating more information abouthow to make thebest appropriate useofthe b. and cycling. and cycling. systems that allows andprotects usersengaginginactivitiessuchaswalking, jogging,running ongoing transformation andexecution ofnew works suchasbetter walkways onourroad T USEOFAVAILABLE RESO URCES ANDENURINGU amilies andc ommunities

TAINED PROGRESS 79 Chapter 7 80 Chapter 7 The mainthrusts willinclude: Health practiti oners 7. 6. 5. 4. 3. 2. 1. 5. 4. advisory structures reviewing practices and services provided. between practitioner andacademiccommunities andinvolvement ofresearchers in acknowledge theaddedvalue ofprofessionals involved inresearch, closerliaison opportunities for protected timefor research initiatives, career pathways that teams ofhealthpractitioners. Examples canincludetheprovision ofincreased Encourage andfacilitate theuptake ofresearch projects by individualsand population. models ofservice that are congruent andresponsive withtheevolving needsofthe and supportsoasto beableto introduce andconsolidate new care services and This willallow for thedeployment ofmotivated professionals for furthertraining expertise inareas ofspecialinterest andincreasing needfor service provision. Augmenting the practice ofissuing callsfor professionals to furtherdevelop their special care needed: professionals ontheseareas. Examples ofthesesectors includetheprovision ofthe available services provided, andproviding generictraining to healthandsocial care Identifying areas ofincreasing needfor or‘unmetneed’from the currently will beconsidered. (particularly ininnovation) by family doctors orgroup practices into theirpractice sector. Financialandotherincentives to supportcapitalandotherinvestments support thesettingupofmore group practices intheprimaryhealthcare Developing theappropriate legalandregulatory framework to encourage and with ahighsuspicionofmalignantdisease. using fast-track mechanismswhere indicated, suchasinthereferral ofpatients to theappropriate specialist in-patient orout-patient service andto refer patients Creating guidelinesandcriteria to helpfamily doctors to refer patients correctly continuing into alllevels ofpostgraduate education andtraining programmes. chronic non-communicable diseasesstarting from theundergraduate level and Increasing training onprimaryhealthcare, rehabilitative care andmanagementof professionals aswell ascontinued professional development. Strengthening thescope ofperformance measurement andassessment for health the different groups ofhealthprofessions. Issuing information to educate thepublicandhealthprofessionals ontherole of sectors withinthehealthsystem. Issuing regular anddetailedinformation ontheperformance ofthedifferent e. d. c. b. a. in resuscitation techniques. in pre-hospital care ofemergencies by patients needingpalliative care, by personswitheating disorders, by frail olderpeopleandpatients withdementia, to thehealthcare needsofvarious sectors ofthepopulation. Actions willinclude: capacity andimpactthat theprimaryhealthcare andcommunity services canhave withrespect The majordrivingforce willbeaimedat expanding therange ofservices, andthevolume, Health careorganis 8. 7. 6. 5. 4. 3. 2. 1. diagnosis andintervention, facilitate referrals to specialist care whenrequired. acute general andrehabilitation hospitals.These unitswillaimtowards increasing early with dementia.These unitswillwork incloseliaisonwiththespecialist unitsinthe Developing dementiaspecialist unitswithinthecommunity to assess andcare for persons available. to clinicalprevention ofdentaldiseaseandimproving theprimarydentalcare services Providing adentalservice that focuses ontheneedsofpatients particularly inrelation hospitals soasto reintegrate more patients withinthecommunity. and community services willbeprovided for suitablepatients presently withinmental efficient andoriented towards the communitymentalhealthservices. More rehabilitative Updating themanagementstructures ofthementalhealthsector to make themmore programmes. These willinclude: Strengthening thedelivery ofcomprehensive, effective andaccessible rehabilitation sector vis-à-vis thesecondary healthcare sector. Enforcing measures that promote thegate keeping functionsoftheprimaryhealthcare condition andevaluation ofpatient’s care. specific chronic diseasemanagementparticularlyinpatient education, monitoring ofthe nurse withtheexpansion ofspecialisednurse-ledclinicsandservices. Training nursesin Increasing andconsolidating therole oftheprimaryhealthcare nurseandthecommunity be appropriately managedat thishospitallevel. result, willbeableto cater for more casesandpatients onthewaiting lists that canonly appropriately managedinthelatter sector willbedevolved from theformer whichasa the secondary to theprimaryhealthcare sector. Inthisway more casesthat canbe services, particularlyinfollow-up andrehabilitation care andto shiftmore services from care sector to increase theircapacityto provide awiderrange ofhealthandsocial Restructuring andinjecting furtherinvestment incommunity services andtheprimary and follow-up ofspecific conditions andchronic illnesses. Increasing thenumberandcapacityofclinicsinprimaryhealthcare for the management c. b. a. communicable diseasesto theprimary healthcare andcommunity services sector. where indicated, shiftingrehabilitation care andmanagementofchronic non- care services. Inparticularspecialattention willbegiven to the: actively pursuingandaugmentingthe numberofprofessionals working inrehabilitation groups strengthening andintroducing programmes targeted at specific conditions andage extending theservices ofalliedhealthcare professionals suchasphysiotherapists • evaluation andaugmentation asnecessary ofthecapacityrehabilitation • rehabilitation process. to operate alsoduringweekends to ensure that there isnobreak inthe service to provide psychological therapy andsocialcare ations

81 Chapter 7 82 Chapter 7 Other importantthrusts willfocus on: 11. 10. 9. resources andtraining. Activities willfocus oncontinuing with: Continuing withtheupgrading oftheprocesses intheorganisation ofhuman pathway. patient willbeinvolved inthedecision-makingprocess involving her/his care with thepatient’s family doctor. Where appropriate andasmuchpossible the involved. This pathway willbecommunicated anditscoordination willbeliaised pathways ofpatients are decidedonat thislevel by alltheprofessionals to helpinthebetter development ofnewer structures. Inthisway thecare on breast cancer whichistheonlyformalised team to date, willbeevaluated oncology andnon-oncology sectors. The work ofthemulti-disciplinaryteam multi-disciplinary team meetingsonspecifiedgroups ofpatients bothinthe develop, supportandformalise thedevelopment andregular organisation of Improving partnershipsacross sectors anddisciplines.Actions willseekto services. Actions willinclude: Improving theresponsiveness to demandandtacklingwaiting lists for health d. c. b. a. e. d. c. b. a. ensuring jobsecurityofhealth professionals, upgrades ofcollective agreements, changes intheHumanResource recruitment practices accordingly, identification ofthe relevant andchanging recruitment drivers andperforming capacity building,needsassessment andfuture planningexercises, primary to specialist care. This could beachieved by: Formalising thefast-tracking ofreferrals ofpossible cancer patients from the current infrastructure andequipmentinuse. introduce new surgical, imagingandotherinvestigative techniques andupdate procurements are neededto increase capacityfor anincreased workload, available, indifferent sectors ofourhospitalsbothinMaltaandGozo. These us to procure new orupgrade thesophisticated medicalequipmentrequired or Seeking to applyfor andbenefitfrom allpossible opportunitiesthat canhelp crises. approach to identifyandaddress causesthat candecrease thelikelihood for and emergency care. Onemethodologycaninvolve acasemanagement possible causeswhichare leadingtheseindividualsto seekrepeated medical Identifying frequent usersespeciallyofemergency services, andanalysing the expanded. needs. The re-direction policy inthetriagearea willbefurthersupported and to settingswhere they canreceive thecare that isthemost appropriate to their that stays are reduced where possible, andpatients are transferred more rapidly Increasing thefrequency ofassessment ofpatients intheadmission wards so directly working inareas where there are longandpersistent waiting lists. Increasing andre-structuring theservice hoursofhealthcare professionals increasing thecapacity(humanexpertise, equipmentandrange of • allocating dedicated slotsinsurgical timetablesfor urgent diagnostic • dedicating slotsinspecialist out-patients clinicsandmedicalimaging • neoplastic disease. investigations available) ofthepathology laboratories for thediagnosisof surgery departments for urgent cancer investigations above domains.They willconcentrate on: The mainthrusts willaimat leading,governing andcomplementing theactivitiesincludedin Health authorities 5. 4. 3. 2. 1. objectives: levels inthehealthsystems. Astrategic planwillbedeveloped that willinclude the following Continuing investment, development andincorporation ofICTtechnologies at multiple information material aswell aspsychological andothersupport(such asbefriending). development ofliaisonswithrelevant voluntary organisations to provide updated Further supportingpatients andtheircarers by encouraging andsupportingthe affiliated witha regularprimarycare general practitioner or group practice. can bealsocoordinated by otherspecificprofessionals. Patients willbeencouraged to be patient partnercoordinator can bethefamily doctor althoughspecialized aspectsofcare Encouraging andsupportingthesetting-upofpatients care pathway coordinators. The in thiscentre willincludeneuro-rehabilitation andtrauma andamputee rehabilitation. maintaining socialinclusionandre-integration. New specialisations that willbepromoted from theacute institutional care settingsto community-based care thusassisting and centre willbeto address theacute needfor effective and rapid transition ofpatients the latest innovation inICTespeciallyassistive technologies. The mainaimofthenew services. The new infrastructure willalsoincludetheinvestment in,andemployment of, will beableto provide comprehensive in-patient, out-patient andoutreach rehabilitation Investing inthedevelopment neededto create adistinct new Rehabilitation Centre that consistently fostered. strategic move andmaximiseuse, community trust inprimarycare facilities needsto be coordinated from thissector. To ensure thefullest possible effectiveness ofthis early intervention, holistic rehabilitation andsupportcanonlybegiven by, and possible healthcare for ourpopulation that isprincipallydirected toward prevention, Re-positioning primaryhealthcare inthecentre ofthehealth care system. The best e. d. c. b. a. e. ICT inMalta. to implementastrategic planoncontinuous investment anddevelopment ofhealth further developing andinvesting inthehumancapital required that willbeempowered infrastructure creating andestablishing ascalablecorporate, robust andinteroperable healthICT direct patient involvement care, fast andefficient service delivery, patient safety through decisionsupport,and empowering healthprofessionals andpatients through ICTto facilitate continuity of productivity andcost savings onlabourandmaterials healthcare system asawholeby achieving better healthoutcomes, increased planning andinvesting inhealthICTthat willbe geared to bringbenefit to the patients andservice providers the myHealth system willbefurtherdeveloped andrendered more user-friendlyfor governance. structural, administrative andlegalchangesto consolidate financialandHR 83 Chapter 7 84 Chapter 7 7.3

ENSURE CONTINUITY OF CARE CARE OF CONTINUITY ENSURE OVERALL OBJECTIVE EFFORT 3-A JOINT TO workers supported by robust information systems. Improve qualityofcare by ensuringconsistency ofcare delivered by competent health are elaborated below. communication technologies (ICT)to Malta’s healthsystems. These actionsandtactics growing demandfor efficient, effective, and economicapplication of information and A numberofstrategic directions andactionshave beenearmarked to address the c A available to theMinistry over thetimeframe ofthisStrategy. These needswillbeimplemented according to thefinancial resources that willbemade ommunication technl ctions t 3. 2. 1. 6. development of: Identified strategic directions andactionsincludethe development orfurther Empower health professionals andpatients through ICT Achieve better value for money by: This willbeachieved through: Further development ofthemyHealth ande-healthsystems abroad orbenefitingfrom family-friendly measures. retaining andre-attracting programmes particularlyfor staff that isundergoing training managed. Evaluation willalsoneedto beperformed to assess theeffectiveness of staff supply ofprofessionals inspecificfieldswill continue tobeidentified,pursuedandactively outcomes andbenefits to thenational healthservices. The lacunaeor‘unmetneeds’inthe specialisation needsandconsequently training received, expertise acquired andthe Regularly updating theHealthHumanResources Strategy to evaluate training and a. d. c. b. a. d. c. b. a. care at Government hospitals A new suite ofclinicalandadministrative applications to supportthedelivery of patients andthegeneral public platform that better supportstheprovision ofinformation-rich content to The migration planoftheMinistry for Health’s web portalto anew hosting continuity ofcare inthedelivery ofacute care, even inthecross-border scenario The National Patient Summarysystem asthefundamentalcorner-stone for transportation costs Digitising paper-basedmedicalrecords to save onstorage, filingand for otherhealthcare system assets medicinal products andmedicaldevices, aswell asasset managementsystems Implementing acomprehensive Stock andInventory Control system for services Studying thefeasibility ofalternative authentication mechanismsfor specific Increasing theservices anddata sources available inthemyHealth system Promoting theuptake ofmyHealth ande-health services Upgrading themyHealth Portal to render itmore user-friendly o devel op thes ogy inHealth (Health ICT) trategic o verarching roleofinformation and implementation ofahealthsystems-wide patient safety policy andsupportinglegislation. The aimisto operate withintheestablished professional codes ofconduct andbest practice care guidelines,andthe facilities andequipment,ensuringtheavailability ofqualifiedandtrained professionals that respect and These willincludetheenforcement ofappropriate standards for, andcomplements of, healthcare leadership functionsandstructures particularly inthesector for theapplication ofquality standards. strategy ispromoting theconsolidation andcontinuing development ofthehealthregulatory and accountability andfor fostering people’s trust andconfidence inthenational health systems. This Quality assurance mechanismsare especiallyimportantfor healthsystems, transparency and Ensuring andenhancingapatient safety culture isanintegral partofthenational healthsystems. and systematic application ofcasemanagement protocols. Setting andenforcing qualitystandards includinglicensing andaccreditation anddevelopment ES Strategic Direction 3A 6. 5. 4. TABLISHING Develop Malta’s humancapitalinhealthICT. This willentailthe: Establish arobust andinteroperable healthICTinfrastructure by: through implementing: Create ascalablecorporate healthICTarchitecture. This objective willbeachieved d. c. b. a. d. c. b. a. b. a. d. c. b. educational activitiesbasedontraditional andsocial mass media Promoting healthICTskillsinthegeneral population through information and conjunction withtertiary educational establishments Increasing thenational healthICTskillsbase thoughspecifictraining initiatives in conditions Recognising thestatus androle ofhealth ICTpractitioners through adequate working more effectively Provision ofexisting healthICTpractitioners withtheknowledge andskillsto work professionals identification, authentication andauthorisation services to front-line health Working withIdentityMaltaand MITA to provide reliable anduser-friendly Creating anew hosting infrastructure to supporte-healthapplications collaboration withstatutory councils Further developing theexisting electronic registers ofhealthprofessionals, in delivery sites Implementing anadequate network infrastructure at allGovernment healthcare record (NEHR)whileprotecting thefundamentalrightto privacy. A legalframework that supportsthedevelopment ofanational electronic health personal healthdata. The national healthdata standards to facilitate thestructured storage andsharingof general public that better supportstheprovision ofinformation-rich content to patients andthe The migration planoftheMinistry for Health’s web portalto anew hosting platform of care inthedelivery ofacute care, even inthecross-border scenario The National Patient Summarysystem asthefundamentalcorner-stone for continuity sector andalsosupportscross-border recognition ofprescriptions An eEntitlement/ePrescription /eDispensingsystem that spansthewholehealthcare TAND ARDS WITHIN AP ATIENT -CENTERED APPRO ACH 85 Chapter 7 86 Chapter 7 times. Actions include: and maintainhighstandards for patient safety practices andsafeguard patients’ dignityat all inclusive ofdefinedlinesaccountability. Allhealthpractitioners willbe expected to uphold initiatives willincorporate thedocumentation ofprocesses involved inproviding services All initiatives are aimedtowards increasing standards inprofessional development. These Health practitioners A numberofmeasures willbeimplemented. These include: Indiviuals, f systems isessential inorder to succeed intheattainment ofalltheobjectives ofthisstrategy. further development andincorporation ofICTtechnologies at multiplelevels inthehealth (ICT) to Malta’s healthcare system, aimedhelpingto improve continuity ofcare. Investment, efficient, effective, and economicapplication of information and communication technologies All theabove andseveral otherdevelopments are feeding into thegrowing hugedemandfor collective publichealtharena. more intherole ofdecision-makers at boththelevels oftheirindividualcare aswell asinthe and endorsedonanational level andcitizens willbe encouraged andsupported to engage patient outcomes are importantprinciples.Patients’ rightsandresponsibilities willbedefined Furthermore, recognizing patients asaresource andaspartners,beingaccountable for reported adverse events are averted. well asat thesystems level suchthat factors leadingto mishapsare corrected andrepetitions of foster alearningculture across allhealthsystems bothat thelevel oftheindividualoperator as 3. 2. 1. 3. 2. 1. their respective group such as intheorganisation andcoordination oftraining specialities intheirwork to further increase theprofessional standards of Supporting andencouraging associations ofhealthprofessionals andmedical recruited healthprofessionals willcontinue to be organised. programme for newly recruited employees. Inductioncourses for allnewly programmes for allgroups ofhealthcare professionals andpilotamentoring Continue withthedevelopment andimplementation ofthecompetency content andlevels ofcompetence to beachieved). groups andinraising thestandards ofallthesedeliverables (withspecified specialisation andcontinued professional development ofallhealthprofessional Consolidating and continuing investment intheprovision oftraining, carers to ensure that thepatient hasallthesupportrequired. accordance withtheconsent ofthepatient theseinitiatives willinvolve thefamily/ professionals to follow theagreed care protocols. Where necessary andin Providing information andeducation ontheimportance for patients andhealth health professionals inthedecision-makingprocess. diagnostic and treatment optionsto allow themto beactive partnerswiththe Ensuring that patients are given effective andsufficient information regarding their patient safety practices andbenchmarks. will alsoaimtowards informing anddirecting thedemandand awareness on the roles, responsibility andrightsofhealthprofessionals. This awareness raising Raising publicawareness abouttheirhealthrights andobligations andalsoabout amilies andc ommunities will bepublishedto dealwiththisvery importantmatter. The mainactivitieswillcentre on: for patient safety. These strategies willbecompliant withthelegislation andotherpoliciesthat The mainthrusts willbeintheimplementation ofastrategy orstrategies to foster theculture Health careorgani s 2. 1. 8. 7. 6. 5. 4. imaging processes willcontinue to beinstituted. Quality assurance andperformance monitoring ofoperations suchaslaboratory and create andsupporttheappropriate structures that canleadandoversee theseactivities. referral pathways to thecompetent specialist services. Investment willbeexpended to for asmany different diseases andgroups ofdiseasesaspossible. These willinclude Increasing, updating, implementingandmonitoring theuseofnational clinicalguidelines be consolidated orcreated. patient safety, andfollow-up theimplementation andevaluation ofthesechangeswill changes to thesystems that are found to have unacceptable risksfor, orlevels of structures neededto evaluate reports, issue recommendations for improvements and of patient safety standards inprimary, secondary andlong-term care. The appropriate quality indicators to enableinternational benchmarkingfor standards, andinparticular The development, implementation andcoordination ofprocedures for thereporting on circumstances ofthepatient. health professional orperhapsasocialworker dependingonthespecificneedsand several healthprofessionals. The key worker canbeamedical doctor, anurse, anallied duplication andto helppatients whocanotherwisebeoverwhelmed withinput from worker’ orpatient coordinator canbeaninstrumental strategy to helpdecrease the community. The earmarkingofakey worker alsoneedsto beconsidered. A‘key These pathways willinclude theroles ofbothformal andinformal carer supportin that encompass patient movement from acute, to rehabilitation, to primarycare. Developing planningandco-ordination frameworks for thecreation ofcare pathways decision support,anddirect patient involvement. to facilitate continuity ofcare, fast andefficientservice delivery, patient safety through Empower healthprofessionals andpatients through ICTsystems that willbedeveloped community. any abuseencountered whenvisitingpatients beingcared for ininstitutions andinthe and community nursesto beonthealertfor, andaware of, processes for reporting Educating healthprofessionals working incommunity medicineespeciallyfamily doctors the area offamily medicine. professional trainers andmentors ofspecialist trainees. There willbespecialemphasisfor Encouraging andsupportingexperienced healthprofessionals to take uptherole of of healthprofessionals. across theboard greater appreciation oftheimportance of‘soft skills’inthepractice and thecorrect application of‘informed consent’. This strategy aimsat achieving an approach to diseasemanagement,abilityto discern patients’ goalsandexpectations attention willbegiven to communication skills,ethicaldecision-makingandan graduate andpost-graduate education inthearea oftraining in‘soft skills’.Particular Increasing thenumberandupgrading thecontent oftraining hoursinbothunder- health practitioners inpreparation for whenthiswillbecome arequisite. participation incontinued professional development programmes andinitiatives for advancement opportunitiesandintheupkeep ofanupdated record ofattendance and and continued professional development, inthedevelopment ofimproved career ations 87 Chapter 7 88 Chapter 7 S Strategic Direction 3B The mainthrusts willfocus on: Health authorities Actions revolve around thefollowing thrusts: Indiviuals, f practices andthepotential ofpersonalisedmedicinewillbepromoted. effective, patients will continue to become more empowered to undertake self-care health system. Service delivery willberelocated ascloseto homeasissafe andcost- strongly reinforcing therole ofprimaryhealth care asthecornerstone ofthenational necessary between thehealthcare andthesocialcare services. This strategy willbe and institutional care, between theprivate andpublichealthcare sectors andwhere process ofcare for any particularpatient between community, primary, secondary are not‘lost’inany partofthesystem. The ultimate aimisto introduce aseamless delivery pathways are integrated sothat continuity ofcare isensured andpatients services canonlybeachieved iftheactivitiesofdifferent players inthecare Continued quality development andperformance enhancement ofthehealth service provider teams, andimproving communication andsharingofinformation. Facilitating continuity ofcare through co-ordination andintegration withinandbetween AFE, HIGHQUALITY 4. 3. 2. 1. 1. assessments for new pharmaceuticals andtechnologies. Increasing andsupportingstructures assigned withconducting healthtechnology is ensured that standards ofcare are maintainedandcontinuously improved. inspections onpublicandprivate healthcare andlong-term care facilities sothat it One oftheaimswillbeto increase thefrequency andthespread oftheregular structures have sofar beenhampered by theunavailability ofadequate resources. protocols andpractices. The expansion ofandprogress onthework ofthese the creation andenforcement ofstandards inhealthcare facilities andofcare Increasing thecapacityof, andtheexpertise, inthestructures responsible for Implementing theprovisions ofthenewly enacted MentalHealthAct (2012). be acquired awareness andknowledge aboutthislegislation, andto ensure itsenforcement will safety. The acquisition oftheresources neededfor the education to raise Concluding andbringingbefore Parliament legislation concerned withpatient through: wherever thepatient canrequest advice andreceive care. This willbe achieved Access to thisinformation istheprerogative ofthepatients andshouldbeavailable investigations andotherrelevant documentssuchashospitaldischarge summaries. Encouraging andintroducing more facilities andtechnologies that enableaccess to b. a. optimisation ofthebenefit to patient care and follow-up. technologies suchaswhenever there isjointcare ofthepatient for the ongoing information to thehealthprofessionals onhow to applythese be usedandto whomthey cangive access. ongoing education to themembersofpubliconhow thesetechnologies can amilies andc , ANDEFFICIENTSERVICES ommunities

Other foci for attention include: by thenational healthsystem. A majorthrust will focus onincreasing themulti-disciplinaryapproach inalltheservices given Health careorgani s to engagein: The majorthrust willbeintheprovision andempowerment ofprimaryhealthcare professionals Health practiti oners 2. 1. 3. 2. consolidate services for the: Strengthening thetreatment abroad services structures sothat itcancontinue to will beintroduced. This necessitates that: backing. Furthermore, new multi-disciplinaryteams for more diseasesordiseasegroups New services willbeintroduced inconjunction withamulti-disciplinaryapproach and and working towards similaraimsinothercountries andat theEUlevel. introduce andfoster contacts withassociations representing similargroups ofpatients and advice onself-care post-diagnosis andtreatment. New groups may beassisted to These groups offer support to patients andtheir families suchasthrough befriending Facilitate andsupporttheinception ofmore self-helpandpatient supportgroups. appropriate. of relevant written information andtheinvitation to accompany thepatient where rehabilitation care. This canbecarriedoutindifferent ways suchas by thedissemination encouraged andsupported, to increase theirinvolvement where necessary, inparticular Following thepatient’s consent, informal carers (particularlyfamily andfriends) willbe a. c. b. a. d. c. b. a. c. Malta, transfer ofpatients abroad, continuation ofcare ofthesepatients ontheirreturn to meetings. the roles andresponsibilities ofalltheprofessionals involved at multi-disciplinaryteam benefit ofdiscussing andimplementingthecare pathway for apatient takinginto view the engenderingofattitudes that willreinforce thevalue oftheseteams andthe meetings willbeprovided. administrative andICTsupport,protected timeto allow attendance to these the necessary resources suchasappropriately equippedmeetingvenues, also berequired to attend andparticipate. appropriate professionals from outsidethehealthsector suchassocialworkers will be required to regularly attend andactively participate inthesemeetings.Where all theprofessions that cancontribute to improve thepatient care pathway will between thedifferent players involved inparticularcare pathways. the establishment andmaintenance ofbetter communication andliaisonchannels specialised fields opportunities for networking between allhealthprofessionals working inparticular dementia care andhealthpromotion. furthering skillsandknowledge inspecialist areas suchassexual health,palliative care, the supportofinformal carers. procedures between theprimaryandsecondary healthcare systems. supporting theimplementation ofclearer managementofinformation sharing ations 89 Chapter 7 90 Chapter 7 in theabove domains.They willconcentrate on: The mainthrusts willaimat leading,governing andcomplementing theactivitiesincluded Health auth orities 3. 2. 1. 6. 5. 4. 3. facilitate decision-makingbothby thepatients andthehealthpractitioners. dissemination ofinformation onpatients to ensure continuity ofcare andto Increasing thetake upintheuseofICTtechnologies that assist inthe appropriately skilledcarer workforce. the relevant regulatory structures) to ensure theupholdingandup-skilling ofan and socialcare workers andthehealthsocialcare authorities(including Increasing collaboration between thevocational training institutions for health the dissemination of thisapproach. services andproviding for thenecessary infrastructure andsupportto ensure Promoting multi-disciplinaryworking inallaspectsofthenational health e-dispensing. tracking ofmedicinalsandmedicaldevices, e-entitlement, e-prescribing and will pave theway for further communication possibilities suchason-lineordering, facilities withnew systems that spanthewholehealthcare sector. These systems Extending ITservices that are inter-operable withinandbetween healthcare deemed to betrulypatient-centred andgoodpractice. professionals are receiving up-to-date information anddelivering services that are Continuous training andre-training ofhealthcare professionals to make sure that will bemadeavailable. these documentsandto widenaccess to allprofessionals that willneedto view them along thecare pathway. The facilities to furtherdevelop theelectronic mobilityof influence that the standard oftheinformation they contain willdetermine theprogress forms. The value ofthesedocumentswillbestressed, inparticularby emphasisingthe move to otherprofessionals withthepatient suchasreferral andhospitaldischarge Educating healthprofessionals onthecorrect completion ofdocumentsthat will will have aprominent andintegral role. through acoordinated multi-disciplinarycare approach inwhichmentalhealthservices footprint. The new acute geriatric service willoffer comprehensive geriatric assessments creation ofaninfrastructure that willincludeanew facility withintheMater Deihospital unnecessary admission to long-term residential care. This new service willinvolve the independence, enableearlierdischarge from hospital andprevents premature and specialised care settingsandservices. Appropriate care delivery willprolong patient complex care needs.They candevelop psychiatric andsocialcare needsthat require population. Olderpersonscanhave multipleco-morbidities, poly-pharmacy and Developing anew service to address acute psychiatric care needsinthegeriatric d. c. b. practical training exercises suchasinqualityassurance skills. enrollment inelectronic training programmes, exchange programmes and and incentres abroad. These cantake theform ofexternal visitinglecturers, sharing andmobilityofexpertise between professionals working inMalta (including specialisedlaboratory services), request for specialisedservices andexpertise from centres ofexcellence abroad organisation ofvisitingconsultants’ sessions, 7.4

Special attention willbegiven to: Health practitioners procedures to beusedwhenapplyingfor theseservices andmedicines.Work willfocus on: that are available aspartofthepublichealthcare package andtheentitlementcriteria and The mainactivitieswillconcentrate oninforming thegeneral publicaboutservices andmedicines Indiviuals, f be imposedonfuture generations. system andpossible consequences suchasunnecessary financialburdens willnothave to current population willbeallowed to continue enjoying thebenefitsoffered byourhealth being delivered efficiently. The rationale forthese activities centres ontheintention that the of any new initiatives. Existing services willalsobeincreasingly evaluated to ensure they are at thepointofuse. Emphasiswillbeplaced oneconomic andcost-effectiveness evaluations an increasing burden onthepublichealthsystem whichdelivers itsservices free ofcharge private to thepublichealthcare system. This, together withtheageingpopulation isputting unexpected shiftofasignificantnumberpeopleanddemand for services from the The openingofnew Mater DeiHospital,astate ofthearthospital,hasresulted inan financing mechanisms,entitlementcriteria for care andorganization ofcare delivery. Designing, developing andevaluating sustainable policiesontargeting humanresources, INTEGRATED PLANNINGA Strategic Direction 4A Ensure thesustainability oftheMaltese HealthSystems. SUSTAINABLE HEALTH SYSTEMS OVERALL OBJECTIVE 4–WORKING TOWARDS 2. 1. 2. 1. dealing withcritically-ill orterminally-ill patients. care system. This isespecially importantinthoseareas where thestaff isallthetime services willbeprovided to address stress andburn-outofstaff working withinthehealth health workforce. The necessary infrastructure includingaccess to psychological support ensure theirhighest level ofcompetence. The aimisto optimize theeffectiveness ofthe both physically andmentally, sothat they willfunction to thebest oftheirabilitiesand emphasise theimportance of maintaining thehealthandwell-being ofhealthworkers to enableemployees to maintainagoodandhealthy work-life balance. Activities will care inorder to dealwithstressors that they may encounter at theplace ofwork and Assist healthprofessionals inthepromotion ofpersonalself-management andself- system. towards ensuringcareful decision-makingto ensure thebest possible useofthehealthcare Information campaignsdesignedto inform healthcare professionals ontheirobligations seeking thenecessary supportandguidance for queriesrelated to service delivery. re-designing andimplementinganew customer care setupthat willbeableto assist people services, reducing thenumberofapplications submitted from peoplewhoare notentitledfor these amilies andc S ANESSENTIAL P ommunities

ART OFSU

TAINABLE HEALTH S Y S TEMS

91 Chapter 7 92 Chapter 7 value for money andlay thebasisfor research anddevelopment. Actions willinclude: policies andstandards, to facilitate thecontrolled sharingofdata andresources, achieve ICT systems that willbecoordinated through acorporate architecture basedonagreed is achieved whenpatients require aservice. This requires thedevelopment ofhealth co-ordination ofsupplies,resources andservices provided to ensure that timelyaccess The mainthrusts willbedevoted towards ensuringbetter oversight, managementand Health auth orities Activities willinclude: Health careorganis 3. 2. 1. 5. 4. 3. 2. 1. system. system. the increased uptake results inconsolidating thesustainability ofthenational health These agreements willneedto begeared towards assuring that amajoroutcome of foster increases intheuptake ofprivate healthinsurance policiesby thepopulation. Seeking andembarkingonagreements withtheprivate healthinsurance sector to services provided are efficientandthat value-for-money is guaranteed. monitoring andevaluation ofoutcomes inorder to continuously ascertain that sustainable service. These agreements necessitate anintense level ofconstant and initiatives that canbedemonstrated to bevalue-adding, andto ensure a Seeking andembarkingonpublic-private andpublic-socialpartnershipschemes lists ofallthe departmentsandfor alltheservices offered by thehealth system. Creating acentralised Waiting List ManagementSystem that includesthewaiting particularly inpolicy development. sustain innovation andthat foster theapplication ofwhole-of-societyapproaches Strengthening andenforcing legislation andlegalinfrastructures that promote and job profiles of staff workingwiththehealthservices. upgrading soasto inform thedesignofnecessary training andchangesto the and needsassessments for theidentification ofskillsthat require acquisition or where changeisdeemednecessary following systematic evaluation ofperformance processes suchasbusiness re-engineering to improve systems andoperations The efficientuseof resources will continue tobeaggressively pursuedthrough benchmarks. systems willalsobeutilisedto assess anddetermine expenditure targets and that caneffectively monitor theoperations andoutcomes ofclinicalactivity. These Continuing intheintroduction andenforcement ofperformance assessment systems service. innovative ideas aimedtowards delivering amore efficient,andahighquality the overall managementoftheorganisation withinanenvironment that welcomes Promoting amanagementmodelthat enhances andwelcomes staff participation in of costs incurred andpromote efficiency. to boththehealthcare provider andthehealthcare userto increase awareness transparency. Anexample could bethrough theprovision ofbillinginformation Improving financial control withinorganisations by increasing accountability and ations impro Strategic Direction 4B available to theMinistry over thetimeframe ofthisStrategy. These needswillbeimplemented according to thefinancial resources that will be made actions, whichincreasingly alsoinvolve groups outsidegovernment. government activitieswillbeembarked onwhichare multi-level (from localto global)government Actions willbetaken to improve leadershipandparticipatory governance towards health.Whole-of- applied. measures to stimulate, increase andsupportclinicalgovernance andmedicalleadershipwillbe healthcare systems andthewholehealthcare workforce, theconcepts andimplementation of national decisionsthrough whole-of-government andwhole-of-societyapproaches. Within the Improving governance andempowering future leadershipfor healthandwell-being to influence board thesechallenges. be implemented. Awell equippedcompliment oftrained professionals willbeneededto take on remain strong assets withinthisstrategic managementplanthat willrequire various changesto building amongawidevariety ofstakeholders. Responsibility, ownership andaccountability will tactics andactionswillbetaken to secure coordination through normative values andtrust- societal level through whole-of-societyapproaches that willcomplement publicpolicy. Various Governance andleadershipwilldevolve beyond theMinistry’s level. Itwillbereinforced also at on theirresponsibility for healthwhilerecognising how healthalsoaffects othersectors. be engagedto emphasise theconcept ofhealthinallpolicies sothat allsectors willunderstand andact integration, centred ontheoverall societalgoalsfor whichthegovernment stands. More advocacy will trust, common ethics,acohesive culture andnew skills.Itstresses theneedfor better coordination and 9. 8. 7. 6. 5. 4. important services ancillaryto healthcare suchascertain socialservices. use ofhealthcare service fundsthusreleasing somefundsto allow thecontinuity ofother planning canleadto better prioritisation offuture investments andmore efficiency inthe in order to provide better estimates for planningandbudgetarycalculations. Better Collecting more granular financialhealthinformation from thepublichealth system by enhancingcontinuity ofcare andenablingbetter care inthecommunity. communication between thesetwo sectors. This shouldachieve ahigherstandard ofcare investing inthenecessary information technology andhumanresources, to improve Devising systems that canmanagethebarrierbetween publicandprivate care by make themmore focused towards thosepeoplethat needtheseservices most. Revising thecommunity services andlong-term care entitlementprocess andcriteria to these pathways more efficient. Streamlining theentitlementprocess andcriteria for thedifferent services to try to make to continuously improve theirreliability anddependability. to ensure fair pricing.Procurement practices willcontinue to beevaluated andimproved are introduced into theGovernment formulary. Stakeholders willbeconsistently engaged Ensuring that maximumreference prices are setandimplemented whennew medicines these fundsisperformed inamore timelyandcomprehensive fashion. to thenational healthsystem needto bemore aggressively pursuedso that thecollection of supplement thefinancingofnational health system. Ontheotherhand,any revenues due Studying thesuitabilityofnew oralternative revenue streams that canbeusedto ving leadershipan articip at ory go vernance for health (24) This approach requires building 93 Chapter 7 94 Chapter 7 Actions willconcentrate towards: Health careorgani s informal carers. Examples include: Activities willconcentrate onassisting healthprofessionals to provide better supportfor Health practiti oners by thedifferent healthcare departments.Asa result, peoplewill: achieved ifthepubliciswell informed andeducated aboutthedifferent services offered that peoplecanclearlydifferentiate between primaryandhospitalcare. This canbe and trust inprimarycare. Nationwide promotion campaignswillbedesignedto ensure The mainthrust ofactionwillbeto ultimately increase thegeneral public’s confidence Indiviuals, f 3. 2. 1. 3. 2. 1. an equalpartnerto specialist andsecondary care. Enabling theprimarycare sector to better perform itsrole asagatekeeper andas outlay. Health System. This willincludebetter utilisation ofexternal fundingfor capital Ensuring goodgovernance andefficientmanagementof resources withinthe performance at highlevels. and inclinicalmicrosystems, where leadershipisrecognised ascrucialto achieve middle levels where aconstellation ofleadersare required to supportchange; leadership roles provides vision,direction, andleverage ofculture andclimate; are necessary at macro level, where appointingdifferent healthprofessionals to of managementfor healthcare employees. Clinicalleadershipandgovernance Providing extensive training anddevelopment ofleadershipskillsat different levels implementation ofchange, qualityofcare andpatient safety. also ofshared leadership, hasbeenidentifiedasbeingcriticallyimportantinthe and shared leadershiproles. MedicalLeadership (andfollowership) inacontext Encourage healthpractitioners to seekandtake upmedicalandclinicalleadership hours, to meettheneedsofinformal carers. Allowing more adjustable working conditions for formal carers, suchasflexible to create innovative solutionsto address theseneeds. More research inthisarea inorder to identifytheneedsofinformal carers soas c. b. a. care more ontheseverity andurgency oftheirsignsandsymptoms base theirdecisionofwhetherthey shouldinitiallyseekprimaryorspecialist seek specialist care onlywhenrequired choice for advice increase theiruseoftheprimaryhealthcare level astheirfirst port-of-callof amilies andc ations ommunities Several activitiesare included.The aimisto: Health authorities 5. 4. 3. 2. 1. effects ofill health andinequalitieson every sector. social andpoliticalgainsthat canbeaccrued from goodhealthandthedetrimental exercise ofleadership, diplomacy andpersuasionskillsto better highlighttheeconomic, as healthbrokers andadvocates. This willincludestrengthening involvement through the Increasingly seekto engageininitiating inter-sectoral approaches for healthandacting to provide seamless continuity ofcare, andensure synergy towards national objectives. national strategy soasto prevent duplication ofresources, integrate healthcare services Co-ordinate andconverge services provided by thepublicandprivate sectors withina translated into better qualityoflife for thegeneral public. outcomes. Clearmeasures are neededto establish how theresources invested, are being invested andtheimprovement inthehealthofpopulation andotherdesired health monitored inorder to measure theperformance ofhealthcare professionals, themoney the healthofpopulation by establishing asetofcore indicators that canberegularly Provide better value for money for theinvestment and resources required to cater for of care. to beensured that documentation anddata capture needsto bedoneat, andfrom allpoints health records across sectors andbetween different healthcare provider facilities anditneeds Towards thisend,aneffective standards framework isneeded to supportinteroperability of of peoplebetween countries, thisarea hasgainedincreasing relevance andimportance. and communications systems, withafocus one-medicine. With theincreasing movement Deploy thenecessary infrastructural andcapitalinvestments especiallyintheareas ofIT data they needinorder to monitor theirperformance andbecome more efficient. support inorder to allow themto work inharmony witheachotherandto collect the Provide departmentswiththenecessary technological, administrative andmanagerial 95 Chapter 7

Systems Strategy Systems N the G Chapter 8 8.1 I overnance of of overnance ntroduction major components, including: the importance ofgovernance inimproving outcomes anditcanbedividedinto at least four surrounding accountability. There iswidespread consensus onandincreasing appreciation of Governance inhealthisacross-cutting theme, whichisintimately connected withissues accountability isinvolved with: have theresponsibility to finance, monitor, deliver, andusehealthservices. Specifically, governments, non-governmental organizations, private firms,andotherentitieswhich between various stakeholders inhealth.These includeindividuals,households,communities, Governance andaccountability are concerned withthemanagementofrelationships systems aswell asthegrowing demandby stakeholders to demonstrate results. accountability. This interest isarisingfrom boththeincreased fundingofhealthandcare The growing importance given to issues ofgovernance isdriven by theneedfor greater 4. 3. 2. 1. e. thereceipt ofrelevant information to evaluate ormonitor performance; d. anassurance ofthelevel ofqualityandperformance oftheservices actuallydelivered; c. anassurance that adequate financing andresources are available to deliver services; b. anunderstanding (either implicitorexplicit) ofhow services willbesupplied; a. health service delivery human resources for health health financing health information systems rewards for performance the enforcement ofactionssuchastheimpositionsanctionsorprovision of ational H

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ealth ealth

97 Chapter 8 98 Chapter 8 8.3 8.2

H T I mplementing he Commission inthelightof theCountry-Specific Recommendations The medium-term budgetaryplanfor thehealthsector willbemonitored by theEU growth andwithintheforecasted trends for thenational revenue andexpenditures. years. Any changesintheexpenditure onhealthare inturndependentonthenational framework withinwhichthenational healthsystem willbefundedover thenext few The adoptionandimplementation oftheNHSS isdependentonthebudgetary realised. so that more andbetter healthoutcomes are secured andpotential savings are investments aimedat gettingmore value for money andpromoting smarter spending strategic planofobjectives, strategies directions andactionsthat includereforms and budgetary item oftheNational Budgetinto theforeseeable future. The NHSS isa The national expenditure onthehealthsystem isandwillcontinue to beasubstantial savings from therecurrent expenditure ofthenational healthsystem through relevant EUco-funded streams and projects. Someofthemeasures aimat generating in theNHSS willbesoughtthrough theapplication for and theimplementation of The capitalinvestment required for therealisation ofanumberthemeasures included human andtechnological resources andexpertise. the investment ofsizeable amountofresources whichincludefinancial,administrative, realisation oftheabove goals.Several oftheactionsincludedinthis strategy willrequire achievement oftheobjectives anddirections that have beenidentifiedas key towards the sustainability ofthenational health systems. The NHSS setsthestrategic roadmap for the Government’s intent to continuously improve theresponsiveness, adequacy, qualityand The overarching aimofthisstrategy isto clearlydemonstrate anddocumentthenational identified issues suchasthe: budgetary framework willincludea: finalized NHSS. Itisenvisaged that themethodologythat willbeemployed to determine this NHSS willbe concluded after thecompletion oftheconsultation phaseandpublication ofthe An actionplancomplemented withabudgetary framework for theimplementation ofthe ealth needfor health-care reforms to increase thecost-effectiveness ofthesector and • implementation ofacomprehensive active ageingstrategy, andthestrengthening • long-term sustainability ofpublicfinances andtheneedto improve theefficiency • b. a. budgetary the monitoring ofhealthsystem performance. of thepublicprimarycare provision and reduce thelengthofpublicprocurement procedures outcomes. the predicted increases inhealth expenditure and register improvements inhealth strategic directions andmeasures includedinthisstrategy to influence the rates of ‘bottom-up’ approach that attempts to illustrate thepotential effects ofdifferent to grow to sustain changesindemandfor healthservices underdifferent scenarios ‘top-down’ approach to show therates at whichthenational healthbudgetsneed S ystems the framework S trategy National

(60) that in2013, 8.4

M and upholditsprinciplesvalues. need to bepromoted widelysothat allstakeholders willbeinformed andwillbeableto identify Funding willbesoughtfor thedissemination andthepromotion oftheNHSS. The NHSS will health care expenditure whichwillbemainlydriven by theageingofpopulation. based goodpractices. These measures willbeimplemented to helpcontain theincrease in includes measures that willinvolve there-engineering ofprocedures according to evidence- structures that willaugmentandensure thesustainability of thesystem. Finally, thisstrategy increasingoperational efficiency. Others promote orseek tointroduce new processes and focal pointsand specialfeatures oftheHSPA for thenational healthsystems in Malta include: the focus and theprocesses that thismonitoring andassessment system willinvolve. The general extensive consultation withdifferent stakeholders withtheaimofachieving anational consensus on The designandimplementation oftheHSPA takes into account several aspectsandrequires be usedto monitor theimplementation, progress andachievements ofthestrategy. System Performance Assessment (HSPA). The HSPA willbeanintegral partofthe NHSS. Itwill will continually andconsistently monitored andassessed through theintroduction ofaHealth and review system. Hence, actionstaken inthecontext ofthefuture healthsystems strategy the national healthsystems strategy needsto have aneffective andsustainable monitoring to qualityhealthservices andeconomic sustainability withintheavailable budgetaryresources, To achieve improvement anddevelopment ofthenational healthsystems andto ensure access easuring Acommunication strategy anddifferent typesofreports/output documentsdeveloped • The needfor targeted capacitybuildingto ensure institutionalisation andsustainability of • Aframework that isdirectly linked withthegovernance systems andtools usedfor health • Aperformance monitoring system that covers allpartsofthehealthsystems, suchas • The requirement to assimilate themonitoring oftheimplementation oftheNHSS within • Aimsto useexisting androutinely collected data asmuchpossible. Indicators included • Anindicator network that needsto encompass andincorporate (or extend to) indicator • health professionals. for different stakeholders such aspolicy makers, general public,healthcare providers, and ensure furtherdevelopment that willallow for asustainable impactoftheproject. other interested personsneedto beincreased sothat they cancarryouttheHSPA and the performance assessment processes andfunctions.The capacityofthelocalteam and care inMalta. situation andthesectors ofeducation, employment andsocialservices. perspectives beyond thehealthcontext includingthenational economic andfinancial health care services, healthpromotion andprotection andpublichealthalsoincludes the present structures ofhealthinformation, monitoring andsurveillance. reliability andvalidity. data canberealistically collected andaggregated andreaches relatively highlevels of will beselected onthebasisoftheirrelevance aswell astheextent that therequired system level strategy. further ensure theintegration ofthesevertical strategies withthenew overarching health health strategies that have beenorare beingdeveloped. This willbeaneffective way to frameworks for thearea-specific strategies due to theseveral diseaseorarea-specific health systems performance

99 Chapter 8 100 Chapter 8 8.5

S H teering implementation the N the of change over time, country comparisons, etc.) for assessment ofperformance. of data inthecountry, andfinallydeveloping andagreeing onbenchmarks (goals, available, buildingasetofidealindicators asaninputfor developing thecollection performing aninventory ofexisting data sources, mappingareas where nodata is mapping existing targets andgoalsto atheoretical healthsystems framework, include themappingofexisting indicators, settingrealistic targets for allstrategies, The development andimplementation oftheHSPA involves several activities.These and whole-of-societyapproaches proposed inOverall Objective 4. extend beyond theMinistry responsible for health,inlinewiththewhole-of-government for theimplementation ofthevarious measures inthestrategy. Suchrepresentation may Membership willincluderepresentation from themainstakeholders that willberesponsible this strategy andto ensure timelyandrobust actionacross thestrategy’s various strands. A steering committee willbeestablished to monitor andcoordinate theimplementation of system development andperformance upto andbeyond 2020. review andanend-of-term evaluation oftheprogress achieved inrelation to thehealth All information gathered by thecommittee willbeusedto compile andissue amid-term at regular intervals, willbethecornerstone ofsuchamonitoring strategy. objectives ofthestrategy. Asustained healthsystems performance assessment, repeated accomplishing therequirement for anongoingmonitoring oftheachievement ofthe analysis onthestatus ofthekey actionsandindicators ofthisstrategy withaview to The committee willcommission scientific studies to acquire updated information and of themeasures ofthestrategy uponrequest by thiscommittee. the progress achieved and/or onactionplansand/or financialaccounts in relation to any Health. Allentitiesfalling withintheMinistry’s remit willbeboundto submitreports on The steering committee willconduct itswork onbehalfoftheMinister responsible for ealth 3. 2. 1. expenditure for theimplementation ofthestrategy. To monitor theacquisition ofthenecessary resources andkeep track ofthe strategy andintheattainment ofthefour objectives ofthestrategy To monitor theprogress intheimplementation ofthedifferent actionsofthe To steer theprocess ofimplementation ofthedifferent actionsinthe strategy S ystems S trategy

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