Malta MT Country Health Profile 2019 the Country Health Profile Series Contents

State of Health in the EU Malta MT Country Health Profile 2019 The Country Health Profile series Contents

The State of Health in the EU’s Country Health Profiles 1. HIGHLIGHTS 3 provide a concise and policy-relevant overview of 2. HEALTH IN MALTA 4 health and health systems in the EU/European Economic 3. RISK FACTORS 7 Area. They emphasise the particular characteristics and challenges in each country against a backdrop of cross- 4. THE HEALTH SYSTEM 9 country comparisons. The aim is to support policymakers 5. PERFORMANCE OF THE HEALTH SYSTEM 13 and influencers with a means for mutual learning and 5.1. Effectiveness 13 voluntary exchange. 5.2. Accessibility 16 The profiles are the joint work of the OECD and the 5.3. Resilience 19 European Observatory on Health Systems and Policies, 6. KEY FINDINGS 22 in cooperation with the European Commission. The team is grateful for the valuable comments and suggestions provided by the Health Systems and Policy Monitor network, the OECD Health Committee and the EU Expert Group on Health Information.

Data and information sources The calculated EU averages are weighted averages of the 28 Member States unless otherwise noted. These EU The data and information in the Country Health Profiles averages do not include Iceland and Norway. are based mainly on national official statistics provided to Eurostat and the OECD, which were validated to This profile was completed in August 2019, based on ensure the highest standards of data comparability. data available in July 2019. The sources and methods underlying these data are To download the Excel spreadsheet matching all the available in the Eurostat Database and the OECD health tables and graphs in this profile, just type the following database. Some additional data also come from the URL into your Internet browser: http://www.oecd.org/ Institute for Health Metrics and Evaluation (IHME), the health/Country-Health-Profiles-2019-Malta.xls European Centre for Disease Prevention and Control (ECDC), the Health Behaviour in School-Aged Children (HBSC) surveys and the World Health Organization (WHO), as well as other national sources.

Demographic and socioeconomic context in Malta, 2017

Demographic factors Malta EU Population size (mid-year estimates) 468 000 511 876 000 Share of population over age 65 (%) 18.8 19.4 Fertility rate¹ 1.3 1.6 Socioeconomic factors GDP per capita (EUR PPP²) 29 300 30 000 Relative poverty rate³ (%) 16.7 16.9 Unemployment rate (%) 4.0 7.6

1. Number of children born per woman aged 15-49. 2. Purchasing power parity (PPP) is defined as the rate of currency conversion that equalises the purchasing power of different currencies by eliminating the differences in price levels between countries. 3. Percentage of persons living with less than 60 % of median equivalised disposable income. Source: Eurostat Database.

Disclaimer: The opinions expressed and arguments employed herein are solely those of the authors and do not necessarily reflect the official views of the OECD or of its member countries, or of the European Observatory on Health Systems and Policies or any of its Partners. The views expressed herein can in no way be taken to reflect the official opinion of the European Union.

This document, as well as any data and map included herein, are without prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area.

Additional disclaimers for WHO are visible at http://www.who.int/bulletin/disclaimer/en/

2 State of Health in the EU · Malta · Country Health Profile 2019 805 830 780 730 755 EUR 2000 EUR 3000 Life expectancy at birth,years Preventble EUR 1000 % of adults acute care. improving timely accesstoquality from treatable causesby scope remains toreduce mortality preventable mortalityrates, but have tolow contributed Effectivehealth policies public Effectiveness Per capita spending(EURPPP) with chronic conditionsisanimportant policy goal. in thedelivery of primary care. Strengthening primary care toimprove efficiency andbetterserve thoseliving Service provides universal coverage foracomprehensive benefit package, the while private sector plays a key role high obesityrates among adultsandadolescents pose aserious threat to public health. The NationalHealth Malta’s population enjoys generally good healthandoneofthelongest lifeexpectanciesintheEU. Nevertheless, 1 per 100000population, 2016 Age-standardised mortality rate Obest Bne drnn Smon MT MT MT mortl t mortl t Tretble 784 Highlights 773 2000 Bne drnn 2005 EU EU EU Smon 17 Obest 21 22 87 93 115 2011 157 MT 15 2017 19 19% EU 20 20% 809 824 2017 26% private spending onoutpatientservices, primary care and pharmaceuticals. highest intheEU(34.6%compared toanaverage of15.8%), duetohigh universal coverage, out-of-pocket spending in2017 was thejointfourth the EUaverage of9.8%. Although thehealthsystem provides practically remains below theEUaverage. This equatesto9.3%ofGDP, alsobelow in 2017 was EUR2732, more than60%higherin2007, althoughit expenditure intheEUover thelastdecade. Healthspending per person % reporting unmet medical needs, 2017 EU MT Malta recorded oneofthelargest increases in per capita health Health system inequalities. common among individuals with low education, contributing tohealth slightly above theEUaverage. Many behavioural riskfactorsare more smoking rates among adultshave remained stablesince2008andremain consumption isalsoanincreasing concernamong adolescents. Overall, of 15-year-olds in2013–14 were overweight orobese. Heavy alcohol health challenge. More thanaquarterofadultsin2017andonethird Malta hasthehighestobesityrates intheEU, presenting amajor public Risk factors expectancy andself-reported healthstatus persist. prevalence ofdiabetesis growing andsocioeconomicinequalitiesinlife and disabilities, afarhighershare thantheEUaverage. However, the good health, with 67%oflifeafterage 65spent without chronic diseases cardiovascular diseases. Maltese people spendthemajorityoftheirlives in have beendriven by declining mortalityfrom sometreatable cancersand 82.4 years in2017, which isamong thehighestinEU. These gains Life expectancy atbirthhasincreased substantially since2000, reaching Health status outpatient services. an important issueforspecialist successfully reduced, butremain lists forinpatient care have been groups.income Long waiting low,betweenlittle variation with Unmet needsformedicalcare are Accessibility 0% Hh ncome %01 Countr EU Countr EU %01 State of Healthin the EU ·Malta ·Country Health Profile 2019 EU Countr All 3% Low ncome 6% spending remains a keypriority. a remainsspending efficiency and reduce public towards primary care toimprove delivery away from hospitals long term. Reorienting service risksinthe fiscal sustainability ageingto population some pose projected spending increases due outlook inMalta, favourable economic Despite the Resilience

MALTA MALTA 2 Health in Malta

Life expectancy is among the highest in the EU Women can expect to live almost four and a half years longer than men (84.6 compared to 80.2 years), Life expectancy at birth in Malta was 82.4 years in though this gender gap in life expectancy is smaller 2017, among the highest in the EU and 1.5 years than the EU average (5.2 years). Maltese people spend 1 higher than the EU average (Figure 1) . Life expectancy the majority of their lives in good health, and in 2017 at birth has increased by more than four years since had the highest healthy life expectancy at birth for 2000, higher than the average increase across the EU. women in the EU (73.6 years) and the second highest for men (71.9 years) after Sweden.

Figure 1. Life expectancy at birth in Malta is one and a half years higher than the EU average Yers 2017 2000 90 –

Gender gap: Malta: 4.4 years 85 – 834

831 EU: 5.2 years 827 827 826 825 824 822 822 821 818 817 817 816 816 814 813 812 811 811 809

80 – 791 784 78 7 78 773 76 758 753 749 748 75 –

70 –

65 – EU Sp n Itl Frnce MltCprusIrelnd Greece Polnd Ltv NorwIcelndSweden Austr F nlndBel um Czech Eston Crot Bul r Portu l Sloven GermnDenmr Slov Hun rL thun Romn Luxembour Netherlnds Un ted n dom Source: Eurostat Database.

Mortality rates are declining for of diabetes are the third highest in the EU, which is cardiovascular diseases, but have slightly likely linked to the high prevalence of obesity in Malta increased for diabetes and some cancers (Section 3).

Gains in life expectancy have been driven by a marked In the last 15 years, the mortality rate from breast reduction in the mortality rate from cardiovascular cancer has fallen markedly, declining from the diseases, which fell by almost 50 % between 2000 and highest in the EU in 2000 to below the EU average in 2016 (Figure 2). Cardiovascular diseases nevertheless 2016. The mortality rate from lung cancer, the most remain the leading cause of death for both men common individual cause of cancer deaths in 2016, and women, accounting for two in every five deaths has remained stable and is among the lowest in the in 2016. Cancers were the second leading cause of EU. However, a rising trend has been observed in lung mortality, responsible for almost 27 % of all deaths. cancer mortality in women. Deaths from prostate cancer are among the lowest in the EU and, despite a Considering individual disease-specific causes of slight increase from 2015 to 2016, the overall trend in mortality, one out of every five deaths in Malta in mortality from prostate cancer continues to decline. 2016 was attributable to ischaemic heart disease, Similar progress has not been observed for pancreatic with stroke accounting for 8.3 % of all deaths, making cancer, with death rates in men continuing to rise. it the second leading individual cause of mortality A second National Cancer Plan has been launched in the country. The mortality rate from diabetes that builds on the first plan and aims to further has remained relatively stable since 2000, with a improve prevention and treatment of cancer in Malta slight increase seen in recent years.2 However, rates (Section 5.1).

1: Contrary to the Health at a Glance approach, 3-year averages for life expectancy, healthy life expectancy and mortality rates are not used in Country Health Profiles for Cyprus, Luxembourg, Malta and Iceland. 2: Changes to the coding practice for diabetes account for much of the observed increase in recent years.

4 State of Health in the EU · Malta · Country Health Profile 2019 -100 percentage points). 73.5 %), butthis gap than theEUaverage issmaller (5 report being in good health(77.2%compared to the lowest incomequintile. More menthan women reporting good healthcompared toonly sixinten with nineinten people inthehighestincomequintile disparities among income groups are substantial, being in good healthin2017(Figure 3). However, Three quartersoftheMaltese population reported of self-reported good health between income groups in terms There aresubstantial disparities with HIVremains amajorchallenge. medicines fortheincreasing number of people living being procured. However, meeting thecostsofnew being outlinedandnew HIVtreatment linesare testing HIVkits. Inaddition, anew HIVstrategy is are being supportedby increased provision ofrapid- diagnosis rates, which remain below theEU average, across theEU(ECDC/WHO, 2018). Effortstoimprove contrast toa general downward trend observed have increased by more than50%since2008, in health issue. Ratesofnewly diagnosed casesoverall (ECDC/WHO, 2018), HIVremains animportant public was lower thanin2016(14.5 per 100000 population) newly reported casesof10.4 per 100000 population rate ofnew HIVcasesintheEU. Although therate of In 2017, Maltareported thethird highestnotification healthchallengepublic HIV remainsanimportant Source: Eurostat Database. Note: Thesize of thebubbles isproportional to themortality rates in2016. Figure 2.Cardiovascular diseases remain themaincauses of deaths inMalta 100 % c -50 50 0 hn Brest cncer Prostte cncer e 2000-16(orner Chronc obstructvepulmonr dsese 20 Pncretc cncer Pneumon est Colorectl cncer

er)

Lun cncer Dbetes 60 0 0 10 4 10 8 200 180 160 140 120 100 80 Str o e State of Healthin the EU ·Malta ·Country Health Profile 2019 Source: Eurostat Database, based onEU-SILC (data refer to 2017). population are roughly thesame. Note: 1.Theshares for thetotal population andthelow-income inequalities by income group report beingingood health,butwithsizeable Figure 3. Three quarters of thepopulation inMalta Unted n dom Luxembour Netherlnds Ae-stndrdsed mortlt rteper100000populton,2016 Low ncome Romn Germn Lthun Denmr Hun r Portu l Sloven Slov Bul r Bel um Norw Sweden Czech Eston Greece Fnlnd Crot Icelnd Austr Polnd Cprus Irelnd Frnce Ltv Mlt Spn Itl EU 0 % of dults whoreport ben n ood helth Totl populton 20 Isc hemc hertdsese 40 60 H h ncome 80 100 5

MALTA The Maltese population live over half of life compared to 22.2 years for women). Yet, there is no 3 after age 65 free of health problems and gender gap in the number of healthy life years at

MALTA disabilities age 65 because women on average live a greater proportion of their lives after this time with some Life expectancy at age 65 in Malta is the fourth health issues or disability. Just over half of people highest in the EU. In 2016, Maltese people aged 65 aged 65 and over report having at least one chronic could expect to live an additional 20.7 years, four disease, a proportion that is similar to other EU years more than in 2000. Two thirds of this time countries. However, only about one in eight people in is spent free of chronic diseases and disabilities, this age group report severe disabilities in the form of which is far higher than the EU average (Figure 4). limitations in basic activities of daily living, such as The gender gap in life expectancy at age 65 is over dressing and showering, lower than the average rate three years in favour of women (19.0 years for men across the EU.

Figure 4. In Malta, the majority of years beyond age 65 are spent free from disability

Lfe expectnc t e 65 Mlt EU

6.8 207 199 10 9 9 ers ers 13.9

Yers w thout Yers w th d sb l t d sb l t

% of people ed 65+ reportn chronc dseses % of people ed 65+ reportn lmttons n ctvtes of dl lvn (ADL) Mlt EU25 Mlt EU25

12% 15% 20% 18%

47% 46% 38% 34% 88% 82%

No chron c One chron c At lest two No l m tt on At lest one d sese d sese chron c d seses n ADL l m tt on n ADL

Note: 1. Chronic diseases include heart attack, stroke, diabetes, Parkinson disease, Alzheimer’s disease, rheumatoid arthritis and osteoarthritis. 2. Basic activities of daily living include dressing, walking across a room, bathing or showering, eating, getting in or out of bed and using the toilet. Source: Eurostat Database for life expectancy and healthy life years (data refer to 2017); SHARE survey for other indicators (data refer to 2017).

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

6 State of Health in the EU · Malta · Country Health Profile 2019 Statistics 2019 for adultsindicators. Source: OECD calculations based onESPAD survey 2015 andHBSCsurvey 2013–14 for children indicators; andEU-SILC 2017, EHIS2014 andOECD Health room for progress inallcountries inallareas. Note: Thecloser thedot isto thecentre, thebetter thecountry performs compared to other EUcountries. Nocountry isinthewhite ‘target area’ asthere is Figure 5. Obesity andexcessive alcohol consumption amongchildren are majorpublichealthissues inMalta deaths respectively (IHME, 2018). responsible foranestimated17%and4ofall second-hand smoking) andlow physical activity with tobaccoconsumption (including direct and intake, were linked tooneinfive deathsin2017, vegetable andfruit intake, andhighsugarsalt of 39%(IHME, 2018). Dietaryrisks, including low to behavioural riskfactors, close totheEUaverage Almost two infive deathsinMaltacanbeattributed to behavioural riskfactors Two infive deaths can be attributed 3 Riskfactors Frut consumpton (dults) Phscl ctvt (dults) Veetble consumpton (dults) Phscl ctvt (chldren) Select dots +Effect >Trnsform scle 130% Smon (chldren) Obest (dults) State of Healthin the EU ·Malta ·Country Health Profile 2019 6 the obesogenicenvironment (Section5.1). actions have taken place inrecent years toaddress for and38%forboys).girls A seriesofintersectoral daily vegetable consumption isrelatively high(32% the EUaverage (9%for and16%forboys),girls but Physical activity among 15-year-olds isalsobelow 150 minutes ofmoderate physical activity per week. in five did notundertake the recommended level of adults reported eating vegetables daily, twowhile by intake ofunhealthy foods. In2017, only halfof Mediterranean dietincreasingly being replaced sizes, accesstoready-made foodsandthetraditional factors, such assedentarylifestyles, larger portion obese. These highrates are driven by anumber of and almostoneinthree 15-year-olds in2013–14 were and children (Figure 5). Oneinfouradults2017 and are now thehighestinEUforbothadults Obesity rates inMalta have risenover the past decade health Obesity isamajorpublic threat Overweht ndobest (chldren) Smon (dults) Bne drnn(dults) Bne drnn(chldren) 7

MALTA Smoking rates among adolescents Socioeconomic inequalities have a have declined substantially negative impact on health behaviours MALTA One in five adults in Malta reported smoking daily Sizeable disparities in health behaviours according in 2014, a higher proportion than the EU average. to educational attainment are observable in Smoking rates are higher for men (23 %) than Malta (Figure 6)5. In 2014, individuals who had not women (17 %). Smoking rates among adults overall completed their secondary education were 1.8 times have remained stable since 2008, in contrast to a more likely to report smoking than those with a general downward trend in most EU countries. More tertiary education, compared to 1.5 times more likely positively, smoking rates among 15- to 16-year-olds in across the EU as a whole. Similarly, in 2014 almost 1 the last 10 years have fallen substantially and were in 3 people without a secondary education in Malta the fifth lowest in the EU in 2015. Smoking rates have were obese (28.9 %), compared to 1 in 5 (20.7 %) declined faster among boys than girls, with reported among those with a higher education. Adults with a cigarette use during the past 30 days in 2015 higher tertiary education were also 1.5 times more likely to for girls (17.6 %) compared to boys (11.6 %). undertake at least 150 minutes of health enhancing physicals activity per week in Malta compared Excessive alcohol consumption among to individuals that had not completed secondary teenagers is a public health concern education, although this gap is smaller than the EU average (1.8 times higher among better education Almost one in five adults in Malta reported heavy individuals). The unequal distribution of these health alcohol consumption at least once a month in 2014, behaviours according to education contributes to which is similar to the EU average. Heavy drinking important inequalities in health outcomes and life was more than twice as high for men than women, expectancy. It should, however, be noted that heavy with one in four men compared to one in eight alcohol use was almost 1.6 times higher in adults women reporting binge drinking4 at least once a with a tertiary education compared to those with low month. Heavy alcohol consumption among 15-to education in both Malta and the EU, suggesting better 16-year-olds has declined since 2007, but remains a educated individuals may, to some extent, be more public health concern. Half of 15-to 16-year-old girls likely to engage in risky behaviours related to alcohol and 45 % of boys reported at least one episode of consumption. A cross-sectoral response to address binge drinking during the past month in 2015, above health inequalities and their causes in Malta has been the EU average. launched (see Section 5.3).

Figure 6. Inequalities in obesity and smoking rates according to educational attainment are higher in Malta than the EU average

% of dults Low educton Hh educton

45 % 40 % 35 % 30 % 25 % 20 % 15 % 10 % 5 % 0 % Mlt EU Mlt EU Mlt EU Mlt EU

Obest Smon Hev lcohol use Phscl ctvt

Source: Eurostat Database (data refer to 2014 or nearest years).

4: Binge drinking is defined as consuming six or more alcoholic drinks on a single occasion for adults, and five or more alcoholic drinks for children. 5: Lower education levels refer to people with less than primary or lower secondary education (ISCED levels 0-2) while higher education levels refer to people with tertiary education (ISCED levels 5-8). Inequalities in education may partially be attributed to the higher proportion of older people with lower educational levels; however, this alone does not account for all socioeconomic disparities.

8 State of Health in the EU · Malta · Country Health Profile 2019 measured asashare ofGDP, healthspending inMalta marginally below theEUaverage of9.8%. When health expenditure reach 9.3%ofGDPin2017, only of healthspending from 2008onwards saw total (Figure 7). A significantincrease inthe publicshare yet thisremains below theEUaverage ofEUR 2884 increased by more than60%, toreach EUR2732, past decade. From 2007to2017, per person spending health expenditure per capita intheEUover the Malta hasseenoneofthelargest increases intotal substantially in the lastdecade Health spending has increased percapita Malta andGozo(seeBox 1). company todevelop andmanage three hospitalsin saw the government contract a private, for-profit sector. However, amajorreform implemented in2017 mainly toovercome long waiting listsinthe public a specificservice was outsourced tothe private sector, recently, a purchaser-provider splitonly existed when for primary care andoutpatientservices. Until complementingprivatesector provision, particularly provider of public healthcare services, with the Ministry forHealth. The Ministry isalsothemain regulation andfinancing are centralised underthe coverage residents. toall Health governance, Health Service(NHS)that provides virtually universal Malta’s healthsystemisatax-financedNational practically universal coverage The National HealthServiceprovides 4 over transparency of ownership, withtheoriginal The dealhasundergone muchpublicscrutiny three hospitals have beendelayed. completed, butcapitalinvestment projects inthe The development of themedicalschool hasbeen as well astheconstruction of anew medicalschool. encourage medicaltourism aspart of the project, commissioner of services. Theoriginalideawas to sector withtheMinistry of Healthnow acting asa brings apurchaser-provider spiltinto thehospital a private contractor (Section 5.3). Theinitiative and management of three publichospitals to responsibility for the refurbishment, development public-private partnership in2016 to transfer The Maltese government entered into a Box 1. Apublic–private partnership aimsto enhance hospital capacity Thehealthsystem State of Healthin the EU ·Malta ·Country Health Profile 2019 inequalities (European Commission, 2016). healthy andactive ageing andreducing health developing technology, eHealthanddigital promoting care strengthening, upskilling ofhealth workers, current ESIF programme (2014-20)tosupport primary was underthe afurtherEUR19million allocated Malta’s healthexpenditure during the period. Malta investment for2007-13, accounting for1.2%of forhealthcare allocated 29 million infrastructure role inthehealth sectorinrecent years, with EUR Investment Funds(ESIF)has played animportant Financial supportfrom theEuropean Structural and 12.5% increase in thehealthbudget. nevertheless increased in2016asaconsequenceof as a percentage ofcurrent healthexpenditure pocket (OOP) payments (Section5.2). Publicspending high private expenditure intheformofout-of- tax-financed European healthsystemand reflects This share isrelatively low fora predominantly was 63.6%in2017, below theEUaverage of79.3%. The share of public spending intotalhealthspending GDP growth. health spending absorbed by strong andsustained robust economic performance, which hasseenrising declined from 2015to2017asaresult ofMalta’s system sustainability. maintaining equitableaccess andsafeguarding health in thispartnership improves qualityof care while in order to ensure that government investment function iscriticalto guaranteeing careful monitoring a project fundedby European Structural Funds. This capacity buildinginservice commissioning through Ministry for Healthisintheprocess of developing for delivery of theprojects isundernegotiation. The operator intheUnited States, andarevised timeline to Steward HealthCare, the largest private hospital Audit Office. In2018, thepartnership was transferred contract isnow beinginvestigated by theNational 150 millionwithoutdelivering onobligations. The contractor entering insolvency after receiving EUR 9

MALTA Figure 7. Health spending per capita and as a share of GDP are now close to the EU average

MALTA Government & compulsor nsurnce Voluntr schemes & household out-of-pocet pments Shre of GDP

EUR PPP per cpt % of GDP 5 000 125

4 000 100

3 000 7 5

2 000 50

1 000 25

0 00 EU Itl Spn Frnce Irelnd Mlt CprusGreece Polnd Ltv Norw AustrSweden Belum IcelndFnlnd Czech Eston BulrCrot Germn Denmr SlovenPortul SlovLthun Hunr Romn Netherlnds Luxembour Unted ndom

Source: OECD Health Statistics 2018 (data refer to 2017).

Total health expenditure on outpatient care security legislation or a humanitarian exemption exceeds spending on hospital services are entitled to access a comprehensive basket of publicly provided health services. The majority Outpatient services were the largest function of total of these services are provided free at the point of health spending in 2017 with a 29 % share of total use, with cost-sharing virtually non-existent in the health expenditure, followed by inpatient services public system. The provision of some services, such with a 26 % share. On a per capita basis, spending as elective dental care, optical services and certain on both inpatient and outpatient care is below the formulary medicines, is nonetheless subject to a EU average (Figure 8). Spending on prevention is means test. All medicines prescribed during inpatient more than two times lower than the EU average care in public hospitals and three days post-discharge and accounts for just 1.3 % of total health spending are available free of charge to entitled individuals compared to an EU average of 3.2 %. Low spending on and for outpatient treatment for certain chronic prevention may suggest some allocative inefficiency conditions, but other medicines and medical devices in the health system and strengthening health must be paid for out of pocket (Section 5.2). promotion and prevention remains a health sector priority. Per person spending on pharmaceuticals and The private sector plays a substantial role in medical devices is, however, above the EU average. A providing primary care and outpatient services relatively large proportion of this spending is private due to persistent challenges in funding innovative Inpatient care is provided mainly by public hospitals, medicines that are much needed in the public sector with primary and outpatient care delivered by both through public sources. A number of recent initiatives public and private providers. Long-term care for older aim to enhance availability of cheaper, therapeutically people is delivered by the public and private sectors as equivalent medicines (Section 5.3). Long-term care well as by religious organisations. The private sector spending per capita is also relatively high and is plays a key role in the delivery of primary care despite expected to rise further in coming decades as the the existence of a state-run primary care system, absolute number of older people in Malta increases. with private general practitioners (GPs) accounting for 70 % of primary care visits. This is often due to Entitled individuals can access a cultural preferences, with people preferring not to comprehensive benefit package attend public clinics that operate on a walk-in basis and instead opting for private practices where they Entitlement to public health services in Malta is are able to choose their physician. Private and public practically universal. All residents covered by social GPs act as partial gatekeepers to public outpatient

10 State of Health in the EU · Malta · Country Health Profile 2019 EUR PPPpercp t 1 000 6: first-levelThis allowed nurses toregisterassecond-level nurses andbrought qualificationsinlinewithEUdirectives. average. However, theshare ofGPs within the number ofGPs per capita isnow close totheEU have improved capacity intheGP workforce and and establishing family medicineasaspecialty certain specialities. Improved remuneration forGPs the physician workforcenevertheless for persist and actively recruiting from abroad. Shortages in investing inspecialisation programmes for physicians doctors incollaboration with theUnitedKingdom, a Foundation Coursein2009fornewly graduated previous physician shortages, including establishing in the past 15 years have toaddressing contributed the EUaverage of3.6(Figure 9). A number ofreforms 2000, toreach 4.0 per 1000 population in2018, above The number of physicians hasrisensteadily since the number ofdoctorsand nurses employment conditionshave increased education,Reforms to trainingand Source: OECD Health Statistics 2019; Eurostat Database (data refer to 2017). outpatient market; 4. Includes onlythehealth component. Note: Administration costs are not included. 1.Includes homecare; 2.Includes curative-rehabilitative care inhospital andother settings; 3. Includes onlythe Figure 8. Per capitaspendingonpharmaceuticals andmedicaldevices ishigh public-sector services. private sectorsbeing abletorefer patients back to sector GPsandspecialists working inboth public and creates adefacto “two-tier” system, with private- as a way toavoid long waiting lists(Section5.2). This of pocket tosee private specialists without areferral services. However, many individuals optto pay out 800 600 400 200 0 Outpt ent cre

spend n

of totl

788

858

spend n

of totl

Inpt ent cre 2

714

835 State of Healthin the EU ·Malta ·Country Health Profile 2019 nd med cldev ces

Phrmceut cls spend n

of totl

21%

567

0 The MalteseNursing Conversion Programme of GPsremains achallenge. remains below theEUaverage (22.5%), andretention the physician workforce iscurrently 20.7%, which population. which remains below theEUaverage of5.0 per 1000 since 2010toreach 4.4 per 1000 population in2018, but overall thenumber ofhospitalbedshasincreased has fluctuatedin recent years dueto restructuring, number ofacuteandlong-term care bedsinMalta from European Development Regional Funds. The capacity (Section 5.3), with majorfunding received to improve their physical conditionandexpand hospital sectorhave beenundertaken inrecent years Major refurbishments andrestructuring inthe and retention (Section5.3). migrant workers, posing challenges forrecruitment workforce inthesesettings isincreasingly reliant on staff inhospitalsandlong-term care andthenursing Malta continues toexperienceashortage ofnursing slightly below theEUaverage of8.5. Despitethis, decade, toreach 7.9 per 1000 population in2018, has increased by more thanonethird inthelast nursing workforce. The number of practising nurses strengthened theskills, competencies andsizeofthe the introduction ofspecialistnurse training have

522

spend n

of totl Lon -term cre

19%

516

471 Mlt

spend n

of totl

1% Prevent on

3 35

0 5 6 and

89 11 EU

MALTA Figure 9. Physician numbers have risen but nurses are still in short supply

MALTA Prctcn nurses per 1 000 populton 20 Doctors Low Doctors H h Nurses H h Nurses H h 18 NO

FI IS 14 IE DE

12 LU BE NL SE SI D 10 FR EU EU vere 85 MT 8 U HR LT HU RO EE CZ ES PT AT 6 IT PL S LV CY BG 4 EL

2 Doctors Low Doctors H h Nurses Low EU vere 36 Nurses Low 0 2 25 3 35 4 45 5 55 6 65 Prctcn doctors per 1 000 populton

Note: In Portugal and Greece, data refer to all doctors licensed to practise, resulting in a large overestimation of the number of practising doctors (e.g. of around 30% in Portugal). In Austria and Greece, the number of nurses is underestimated as it only includes those working in hospital. Source: Eurostat Database (data refer to 2017 or nearest year).

12 State of Health in the EU · Malta · Country Health Profile 2019 Source: Eurostat Database (data refer to 2016). to premature mortality (under age75). Thedata are based ontherevised OECD/Eurostat lists. treatable causes isdefined asdeath that can bemainlyavoided through health care interventions, includingscreening andtreatment. Both indicators refer Note: Preventable mortality isdefined asdeath that can bemainlyavoided through publichealth andprimaryprevention interventions. Mortality from average Figure 10. Deaths from preventable causes are low from andmortality treatable causes isbetter thantheEU well astheeffectiveness ofnationalimmunisation have targeted tobaccoandalcoholconsumption, as reflects, in part, strong publichealth policiesthat preventable causesintheEU2016(Figure 10). This Malta hadthethird lowest rate ofdeathsfrom among the lowest in the EU Preventable is inMalta mortality 5.1. 5 Unted ndom Accdents (trnsport ndothers) Ischemc dseses hert Lun cncer Performance of thehealthsystem Luxembour Netherlnds Effectiveness Lthun Germn Denmr Romn Hunr Ae-stndrdsed rtes mortlt per100000populton Portul Sloven Slov Bulr Belum Norw Sweden Czech Eston Fnlnd Crot Icelnd Austr Polnd Cprus Irelnd Greece Frnce Ltv Mlt Spn Itl Preventble cusesofmortlt EU 0 50 100 100 110 115 118 121 129 150 133 134 138 139 140 140 141 Others Stomch cncer Dbetes 154 155 158 161 161 161 166 200 184 195 218 250 232 232 244 262 300 310 325 350 332 State of Healthin the EU ·Malta ·Country Health Profile 2019 336 by ischaemic heartdisease. primary causeof preventable deaths, closely followed among thelowest intheEU. Lung cancerremains the lung cancerand accidents (road andothers)are now programmes. Deathsfrom alcohol-related conditions, Unted ndom Brest cncer Colorectl cncer Ischemc dseses hert Luxembour Netherlnds Lthun Germn Denmr Romn Hunr Ae-stndrdsed rtes mortlt per100000populton Portul Sloven Slov Bulr Belum Norw Sweden Czech Eston Fnlnd Crot Icelnd Austr Polnd Cprus Irelnd Greece Frnce Ltv Mlt Spn Itl EU Tretble cusesofmortlt 0 50 62 62 63 67 67 68 69 71 71 71 76 77 78 80 80 100 87 87 89 90 93 Others Stroe Dbetes 95 128 130 150 140 143 168 176 200 194 203 206 208 250 13

MALTA Deaths from ischaemic heart disease, which is breast cancers was equal to the EU average. On the considered to be preventable both through public other hand, mortality from stroke and pneumonia

MALTA health policies and effective medical care, and were lower (see Figure 10). diabetes remain above the EU average. This is partly attributable to Malta’s high prevalence of obesity. Compulsory immunisations contribute The Maltese government has recognised the severity to high childhood vaccination rates of this issue and has developed several strategies Childhood immunisations are available free of to reduce the prevalence of obesity in adults and charge in Malta, with vaccination against diphtheria, children. Current actions include the Healthy Weight tetanus and pertussis (DTP) also mandated by law. for Life Strategy 2012-20, the Food and Nutrition This contributes to Malta having high immunisation Action Plan 2015-20, and the Non-Communicable coverage for DTP, measles and hepatitis B, with Diseases Act 2016. Regulations in the school vaccination rates above the EU average and the environment on food provision have also recently WHO recommended target of 95 % (Figure 11). been strengthened, with legislation enacted to Vaccination coverage for influenza among people regulate food available in schools and to restrict 65 years and over is high compared to elsewhere in advertising or sponsorship of unhealthy foods. the EU, reflecting extensive use of health promotion Tobacco and alcohol control policies and educational campaigns to promote awareness, are continually being strengthened as well as wide availability of the vaccine, which is free of charge (Rechel, Richardson & McKee, Regulations on tobacco advertising and legislation 2018). However, immunisation rates remain introducing a smoking ban in 2004 have successfully below the WHO recommended target of 75 %. The contributed to a fall in smoking rates among adults national immunisation programme has recently and young people. Many existing laws on cigarettes, been expanded to include the pneumococcal and such as a total ban on advertising and mandatory meningococcal vaccines, with procurement currently health warning on labels, also apply to electronic in progress. cigarettes, which are regulated as tobacco products. New legislation introduced in 2017 prohibits smoking Figure 11. Malta records relatively high vaccination in private cars carrying children under the age of 18 coverage for childhood immunisations and influenza to help limit their exposure to harmful second-hand Mlt EU smoke. Furthermore, a new tobacco strategy is currently being developed. Dphther, tetnus, pertusss Amon chldren ed 2

The first National Alcohol Policy for Malta was 97 % 94 % introduced in 2018, covering a five-year period up to 2023. It recommends specific actions targeting the sale, purchase, consumption and supply of alcoholic products to those aged under 17 to curb Mesles Amon chldren ed 2 underage drinking. Prevention of drunk-driving will be strengthened by introducing stricter penalties for 96 % 94 % drunk-driving offences and lowering blood alcohol concentration level limits. Efforts are under way to translate these policy recommendations into new Heptts B laws and actions. Amon chldren ed 2 Improvements in health system performance 98 % 93 % have contributed to a reduction in mortality from treatable causes

Deaths that can be mainly avoided through timely and effective health care interventions have fallen Influenz Amon people ed 65 nd over by a fifth in Malta since 2011, and their rate is now below the EU average. The overall decline reflects 56 % 44 % improvements in health system performance, with increased access to, and availability of, key services

and innovative medicines and medical technologies. Note: Data refer to the third dose for diphtheria, tetanus, pertussis and In terms of individual causes, mortality from hepatitis B, and the first dose for measles. colorectal cancer in females was higher than the EU Source: WHO/UNICEF Global Health Observatory Data Repository for children (data refer to 2018); OECD Health Statistics 2019 and Eurostat average for 2016, whereas the mortality rate from Database for people aged 65 and over (data refer to 2017 or nearest year).

14 State of Health in the EU · Malta · Country Health Profile 2019 of through theNationalCervicalcancerscreening programme provided by theNHSanduptakerates may becloserto75%ofwomen. 7: Datafrom theEuropean Health InterviewSurvey 2014-2015suggeststhat themajorityofcervicalcancerscreeningisundertakeninprivate sectorinstead presentation toemergency departments, requiring Mortality rates are alsodependent on prompt effective care indedicatedstroke orcardiac units. of care, timely transfer of patients and delivery of elements ofqualityinacutecare such as processes (Figure 13). These indicatorscapture important infarction andstroke are relatively highinMalta Deaths following admissionforacutemyocardial rateshigh mortality persist for heartattack andstroke, but relatively More peoplesurvive following admission Medicine. Source: CONCORD programme, London Schoolof HygieneandTropical Note: Data refer to people diagnosed between 2010 and2014. the EU average for breast andprostate cancers Figure 12.Five-year cancer survival rates are above less thanhalftheEUaverage Cancer Screening programme remains low at32%, cervical cancerscreening through theNHSNational now thesameasEUaverage (60%). Uptake for have shown notableimprovements since2010 andare in 2016. Attendance rates forbreast cancerscreening for women aged between 25and35 years launched with anationalcervicalcancerscreening programme breast andcolorectal cancerforanumber of years, Malta hasoffered national screening programmes for compared to60%). period andisslightly below theEUaverage (58% colorectal cancer hasremained stableover thesame and prostate cancers(Figure 12). Five-year survival for 2010–14 andare now above theEUaverage forbreast improved substantially inMaltabetween 2000–04and Five-year survival rates foranumber ofcancers considerably but screening rates arelow Cancer survival rates have improved and survival outcomes. inequalities inaccesstocancerscreening, cancercare to improving integration ofcare andreducing to strengthen primary prevention. Italsocommits Cancer Plan(2017–27)hasbeenadopted, which aims Mlt EU26 87% Prostte cncer Mlt EU26 60% Colon cncer 88 % 58 % 7 . A secondNational EU26 15% Mlt Lun cncer 15 Mlt EU26 83% Brest cncer % 87 % State of Healthin the EU ·Malta ·Country Health Profile 2019 Source: OECD Health Statistics 2019 (data refer to 2017 ornearest year). for AMIandischaemicstroke. standardised to the2010 OECD population aged 45+ admitted to hospital Note: Figures are based onpatient data andhave been age-sex myocardial infarction isrelatively high Figure 13. following Mortality stroke andacute stroke. campaign both aim toimprove survival following at MaterDeiHospitalin2015anda public awareness introduction of thrombectomy toremove bloodclots knowledge ofsymptoms among the population. The (Ministry forHealth, 2018). awareness of AMR andappropriate use antibiotic stewardship andsurveillance practices, raising and tostrengthening contribute will antimicrobial integrated andsimultaneous actionisrequired strategy setsoutobjectives andbroad areas where AMR Strategy and Action Plan(2018-25)in2018. The response, the government held aconsultationonan of antimicrobial resistance (AMR)(ECDC, 2017). In community, toMaltahaving contributes highlevels hospitals andbroad-spectrum inthe antibiotics of antibiotics, including last-resort in antibiotics EEA (ECDC, 2017). Incorrect andexcessive use year, which was thehighest proportion intheEU/ reported having taken inthe antibiotics past In 2016, almost50%ofthe population inMalta to combat the threat ofantimicrobial resistance A strategy andactionplanhas been developed 20 30 30-d rte mortlt per100hosptlstons 25 10 15 0 5 AMI MT EU17 Stroe MT EU16 15

MALTA 5.2. Accessibility MALTA Unmet needs for health care are low with to access the NHS. The proportion of people who little difference between income groups reported unmet needs for medical care due to cost, distance or waiting times was close to zero in 2017, All residents of Malta covered by social security based on EU-SILC data, with little difference between legislation as well as refugees and asylum seekers high-income and low-income groups (Figure 14)8. covered by humanitarian exemptions are entitled

Figure 14. Levels of self-reported unmet needs are among the lowest in the EU

% reportn unmet medcl needs Hh ncome Totl populton Low ncome 20

EU Itl Spn Greece Ltv Polnd Irelnd Cprus Frnce Mlt Eston Fnlnd Icelnd BelumBulr Crot SwedenNorw Czech Austr Romn Sloven SlovPortul Lthun DenmrHunr Germn Luxembour Netherlnds Unted ndom Note: Data refer to unmet needs for a medical examination or treatment due to costs, distance to travel or waiting times. Caution is required in comparing the data across countries as there are some variations in the survey instrument used. Source: Eurostat Database, based on EU-SILC (data refer to 2017).

The Maltese health system in general provides good population coverage, including for migrants, and Box 2. Recent reforms have expanded access to recent reforms have expanded entitlements to provide care for LGBTQ individuals health care services to minority groups (Box 2). In 2018, amendments to the Embryo Protection Act Nonetheless, some who enter Malta legally but are of 2012 expanded entitlement to in-vitro fertilisation not entitled to work in the formal sector9 are also not (IVF) services to any individual irrespective of gender entitled to receive free public health care. Problems or sexual orientation, enabling same-sex couples in accessing health care are a rising concern for this and single women to access IVF services. In the group, particularly those with long-term conditions, same year, the government launched a document on such as mental health issues or HIV, where initial Transgender Healthcare Services, one of the first of treatment and antiretroviral therapy may be provided, its kind in Europe, which committed to expanding but subsequently discontinued if payment is not medical benefits by including gender identity and received (Vassallo & Borg, 2018). sex characteristics as conditions eligible for free treatment, allowing transgender individuals to access hormone therapy and gender-affirmation care free of charge (Ministry for Health, 2019). This change was implemented as part of a wider strategy to improve transgender services through the delivery of multidisciplinary care in Gender Wellbeing Clinics.

8: A separate survey, the European Health Interview Survey (EHIS), which targets people who have health or dental care needs as opposed to all individuals, shows greater levels of unmet needs for medical care and dental care. In the EHIS, about 5 % of the population reported some unmet medical needs for financial reasons in 2014, with 5 % of the population reporting unmet needs for dental care. The rate of unmet needs for both medical and dental care was higher among low-income groups. 9: For example, those who received humanitarian protection in another EU Member State.

16 State of Health in the EU · Malta · Country Health Profile 2019 population. 2019, corresponding toapproximately onethird ofthe covered foratleastoneoftheirchronic conditionsin through ameans test. Over 140000individuals were belowincome falls abasicthreshold, asestablished List thatare available free ofcharge forthose whose for anumber ofitemsontheGovernment Formulary number ofchronic conditionsasdefined by law and medication. Free medicationis provided foralarge paid foroutof pocket by forfreepeople noteligible free ofcharge, other all pharmaceuticals must be and three days following discharge are available medicines While prescribed during hospitalstays personnel andthoseonlow incomes. children undertheage of16, police andarmedforces and hearing aids are provided free ofcharge to Elective dentalservicesand prostheses, spectacles dental care available free of charge atthe point ofuse. with public health care servicesandemergency Malta’s NHSoffersacomprehensive benefit package, medicines freeofcharge chronic diseasescanaccessessential Low-income groups andpeople with certain assesses whether procedures deliver value for money. reference pricing and external reference pricingand system established in2010, whichapplies maximum supported by aHealthTechnology Assessment (HTA) medicines to theGovernment Formulary List are companies. Decisionsonwhether to add new joint negotiations of prices withpharmaceutical EU MemberStates, whichaimsto facilitate the Valletta Declaration, analliance of southern recent years. Maltaisalso afounding memberof new medicines have helpedfacilitate access in pathways andprotocols for theevaluation of Greater use of Managed Entry Agreements, clinical challenges inensuringavailability of new medicines. As asmallcountry, Maltafaces considerable Box 3. Ensuring access to innovative medicines remains amajorchallenge State of Healthin the EU ·Malta ·Country Health Profile 2019 to promote betteraccesstomedicines(seeBox 3). Other evidenced-based strategies have beenlaunched or added tothebenefit package ina routine manner. should befast-tracked through theexceptional route difficulties indetermining whethernew medicines However, implementation dueto hasstalled assess requests forexceptional medicinaltreatment. In 2018, aspecialcommittee was establishedto face particular challenges inaccessing medicines. and multiple sclerosis. People with rare diseases treatment ofchronic pain, chemotherapy side effects medicalcannabis while was legalisedforthe direct-acting antiviral therapy treatment forfree, patients with hepatitis Care now toreceive eligible Government Formulary List was expanded. All In 2018, thelistofmedicinesincluded inthe professionals remains of key importance. trust of biosimilar medicines by patients andhealth uptake. Indeed,aswithgenerics, acceptance and at pharmacy level are policyoptions that could foster incentives for biosimilar prescription and substitution to new medicines. Better information, introduction of Medical Agency as key strategies to improve access rare illnesses have been highlighted by theMalta generics andbiosimilars, andthenew committee for Stronger European collaborations, greater use of funds for new medicines to enter theformulary. Nevertheless, majorchallenges remain inobtaining collaboration between European HTA organisations. Malta isalso amemberof EUnetHTA, whichsupports 17

MALTA Malta has among the highest Pharmaceuticals accounted for the second largest out-of-pocket expenditure in the EU share of OOP spending due to a large proportion of

MALTA the population being required to pay for medicines In 2017, OOP spending as a share of total health prescribed in outpatient and primary care settings. expenditure (34.6 %) was the fourth highest in the OOP spending on health as a share of final household EU and more than twice the EU average (Figure 15). consumption in 2016 was 5.2 %, the second highest High OOP spending is driven by spending on private share in the EU. primary and outpatient specialist services due to individuals opting for private care (Section 4).

Figure 15. High out-of-pocket expenditure is driven by spending on outpatient care and pharmaceuticals

Overll shre of Dstrbuton of OOP spendn Overll shre of Dstrbuton of OOP spendn helth spendn b tpe of ctvtes helth spendn b tpe of ctvtes

Mlt EU Inptent 16% Inptent 14% Outptent Outptent medcl cre 116% medcl cre 31%

OOP OOP Phrmceutcls 55% 346% Phrmceutcls 85% 158% Dentl cre 22% Dentl cre 25% Lon-term cre 73% Lon-term cre 24% Others 33% Others 09%

Source: OECD Health Statistics 2019 (data refer to 2017).

Waiting times have been reduced for inpatient care Waiting times for outpatient specialist services but still remain an issue for outpatient services remain high for some services, with an average wait of 37 weeks for a first outpatient appointment across all Malta has successfully reduced waiting list times for clinical specialities at the Mater Dei Hospital in 2016.

some inpatient services in recent years by introducing The highest waiting times are for neurology, urology, Others routine Sunday activity and outsourcing certain vascular services, genetics and gastroenterology (NAO, Lon-term cre elective surgeries and diagnostic procedures to the 2017). Long waiting lists for outpatient and some private sector. In 2016, only 0.1 % of respondents inpatient services raise equity concerns over access Dentl cre reported unmet needs for medical care due to Not OOPtoOOP care, with those who can afford to do so paying phrmceutcls waiting times, one of the lowest proportions to access private GPs and specialist outpatient care Outptent medcl cre in the EU. However, this figure masks variation to bypass waiting lists in ambulatory settings and between procedures; while waiting lists have been to gain expedited access to public hospitals through Inptent virtually eliminated for some procedures such as fast-tracked referrals (Vassallo & Borg, 2018). echocardiograms and cataract surgery, they remain longer for others such as orthopaedics.

18 State of Health in the EU · Malta · Country Health Profile 2019 10: Resilience refers10: Resilience tohealthsystems’capacityadapteffectively tochanging environments, suddenshocks orcrises. from acutebedstomore appropriate settings. are preventing themovement ofdebilitated patients suggests that pressures onlong-term care capacity among thehighestinEU/EEAandsomeevidence the EUaverage (Figure 17), bedoccupancy rates are has remained stableinrecent years andisbelow length ofstay (ALOS)inacutehospitalsMalta rising demandforhealthcare. theaverageWhile hospitals inMaltaisinsufficientto appropriately meet The current capacity and physical conditionof andimprovehospitals acutecarecapacity investmentIncreased capital aims to modernise Source: OECD Health Statistics 2018; Eurostat Database (data refer to 2013 and2016 ornearest year). Figure 16. Day surgery inhospitals hasincreased future healthspending growth. health systemremain important goals tomoderate Improving thecost–effectiveness andefficiency ofthe Commission, oftheEuropean 2019;Council Union). riskinthelongfiscal sustainability term(European growth inhealthspending may pose amedium long-term economic outlook, thefuture predicted Although Maltahasafavourable medium-and increase intheEU (European Commission, 2018). GDP between 2016and2070, thelargest estimated is projected toriseby 2.7 percentage points of complex care needs. Publichealthcare spending a growing andageing population with ever more to increase markedly tomeetrising demandfrom In thecoming decades, healthexpenditure isexpected long-term fiscal sustainability challenges age-related healthspending increasespose Despite astrong economicoutlook, 5.3. % of d sur eres 100 80 60 90 40 20 50 30 70 10 0 Resilience Mlt Ctrct 10

EU Mlt State of Healthin the EU ·Malta ·Country Health Profile 2019 In unl hern of artificial intelligence of artificialintelligence robots toassistinsurgeries. equipment atthehospital, including theintroduction specialities. The government isalsoinvesting in new which helpreducewill long waiting timesforcertain block foroutpatientservicesatMaterDeiHospital, the government hascommittedtobuilding anew and rehabilitation. Outside of thenew partnership, refurbished toincrease bedcapacity for geriatric care see GozoGeneral, StLuke’s andKaren Grech hospitals school (seeBox 1inSection4). The partnership will hospitals andtheestablishmentofanew medical for therefurbishment anddevelopment ofthree signed a30-year public-private partnership in2016 In part toaddress theseissues, the government (European Commission, 2019). to undertake work incheaper outpatientsettings proportion ofday surgeries by incentivising hospitals for specialistoutpatientcare may helpincrease the remains low. Greater useofactivity-related payment share forother surgeries such astonsillectomies in ambulatorysettings isabove theEUaverage, the cataract surgery andinguinal herniarepair performed are nevertheless possible; the while proportion of as day surgery (Figure 16). Furtherefficiency gains increasing share ofsurgical procedures performed use ofhospitalresources, asevidenced by the Efforts have beenmadeto promote more appropriate gains in sector the hospital There ispotential formoreefficiency EU Mlt Tonsllectom 2013 EU 2016 19

MALTA Figure 17. Average length of stay in Malta is below the EU average

M lt Beds ALOS EU Beds ALOS MALTA Beds per 1 000 popul ton ALOS (d s) 8 12

6 10

4 8

2 6 2009 2010 2011 2012 2013 2014 2015 2016 2017

Source: Eurostat Database (data refer to 2017 or nearest year).

Strengthening primary care is a priority mental health services are also being made, which will see the refurbishment of the existing Mount Strengthening primary and community care is a Carmel Hospital and the building of a new acute government priority in Malta to help improve health psychiatric hospital. system performance and efficiency. Stronger primary care will support the delivery of comprehensive Integrated care is being strengthened to and continuous care for chronic diseases, and improve diabetes prevention and treatment will contribute to reducing inappropriate use of emergency departments and high rates of avoidable Diabetes is a major health issue in Malta (Section 2) hospitalisations in Malta for conditions including and steps have been taken to improve prevention and asthma, diabetes and congestive heart failure that treatment (Box 4). The first National Diabetes Strategy can be effectively managed in more cost-effective (2016–20) has also been developed. It emphasises the ambulatory settings. need for improved prevention and early diagnosis, an expansion of treatment options and further To strengthen primary care, multidisciplinary and development of integrated care for diabetes (Ministry integrated primary and secondary care teams have for Health, 2019). As part of the strategy, newer been introduced to support the delivery of services for diabetes therapies became publicly available in 2016. the management and treatment of chronic conditions in primary care. The myHealth electronic portal has Although the health workforce has also been implemented to facilitate enhanced access grown, staff shortages and an ageing to patient records for GPs. Moreover, EUR 39 million GP workforce pose challenges (EUR 33 million from EU funds), is being invested in opening a primary health care hub in southern Although Malta has taken a number of steps to Malta, which will serve approximately one third of the strengthen the health workforce (Section 4), many population. Actions to shift long-term care away from challenges in recruitment and retention remain. institutional and hospital settings are being taken by Nursing shortages in the acute and mental health incentivising home- or community-based care by, for care settings have led to a reliance on migrant example, financially compensating informal carers. workers, leading to an unpredictable supply of health professionals. In addition, an ageing private GP Malta has published its first workforce, combined with younger doctors reluctant Mental Health Strategy to support to work in private solo practices, is changing the reform of mental health care model of care needed for primary and outpatient care. Efforts to respond to these challenges and develop a While the burden of mental health has increased workforce with the right numbers and skill mix are over recent decades, investment in improving mental under way and a new health workforce document is health facilities and services has lagged behind. In under development. response, the first Mental Health Strategy (2020–30) has been developed, which proposes a multisectoral approach to promote mental health throughout the course of life and a strengthening of integrated care with service delivery reoriented towards community settings (Ministry for Health, 2019). Investments in developing physical and human resource capacity for

20 State of Health in the EU · Malta · Country Health Profile 2019 reduce healthinequalities alsobeassessed.will health inequalities. Current policy responses to social determinantsinMaltaandtheirimpact on sectional nationalsurvey todocument andreview policymakers andeducatorsoversee across- the unit undertakewill qualitative research with from2.5 million the European Social Fund. In2019, determinants ofhealth, which isfundedby EUR establish anational platform toaddress thesocial key ministriesandcivil societyrepresentatives to health inequalities. The unithas partnered with other coordinate a whole-of-government response totackle Health Unit within theMinistryofHealthtohelp Malta hasestablishedaSocialDeterminantsof from across-policy perspective the socialdeterminants ofhealth isenhancingMalta efforts to tackle diabetic children. provisions offree continuous glucose monitorsto of mHealthapplications is planned, such asthe health registries among others. Enhanceduse hospital records andasystemfor population-based electronic health records in primary care, electronic health infrastructure, including thedevelopment of have tofurtherstrengthen beenallocated digital fromthan EUR9million bothnationalandEUfunds previously only madeby specialistdoctors. More card. Italsoallows GPstomake referrals forservices access medicalrecords onlineusing thenationale-ID care by allowing patients andauthoriseddoctorsto patients andimprove continuity andtimelinessof myHealth electronic patient portal aimstoempower comprehensive healthinfrastructure. digital The Malta istaking steps towards developing a services to improve qualityofcare isinvestingMalta health indigital State of Healthin the EU ·Malta ·Country Health Profile 2019 national healthstrategy forthecoming decade. of documents, which togetherformthenewwill three years. Maltaiscurrently preparing acollection with monitoring undertaken approximately every system performance are measured andassessed, mechanism through which improvements inhealth the firststrategy. This framework now serves asa support from WHO tomonitorimplementation of assessment framework was developed in2015 with performance. A health system performance of strategic directions toimprove healthsystem (2014-2020) in2014, which outlinedanumber Malta adoptedaNationalHealthSystemStrategy governance andhealthsystemeffectiveness Strategic actionsarecontributing to improved and specialist care (Government of Malta,2019). care continuity andenhanced access to primary reduced diabetes-related complications, improved programme hasincreased patient satisfaction, in thecommunity. Government data indicates the population) had beentransferred to receive care 3 000patients (approximately 7%of thediabetic operationalised inallhealthcentres andmore than years of implementation, theprogramme was with specialist doctors. Withinthefirst three Malta andenables real-time consultation of cases serves asaregister of alldiabetic patients in facilitated through acomputerised system that in diabetes. Coordination withthehospital is and ophthalmologists with aspecialinterest care teams consist of doctors, nurses, podiatrists referral to thehospital clinic.Themultidisciplinary care unless there are complications warranting Diabetes shared care ismainlymanaged inprimary Diabetes Department inMater DeiHospital. care healthcentres andtheEndocrinology and shared-care diabetes programme between primary In 2014, Maltaimplemented amultidisciplinary programme aimsto improve qualityof care Box 4. Amultidisciplinary shared-care diabetes 21

MALTA MALTA 6 Key findings

• Maltese people enjoy generally good health and outpatient care. This is partly due to and one of the longest life expectancies in attempts to bypass long waiting lists for the EU. Improved health system performance specialist services and a large proportion of over the last two decades has helped to the population being required to pay out of reduce mortality rates from treatable causes, pocket for some pharmaceuticals prescribed particularly cardiovascular diseases and in these settings. While efforts to reduce some cancers, while public health policies waiting lists for inpatient care have been have contributed to low levels of preventable largely successful, waiting lists for outpatient mortality. Further reductions in mortality services are growing. from cardiovascular diseases have been targeted by increasing timely access to quality • Reforms to education, training and working acute care. The rising disease burden from conditions for health professionals have diabetes and mental health issues has led to successfully increased the number of them being recognised as priorities for the physicians and nurses working in Malta. An health sector. increasing reliance on migrant nurses in acute and long-term care, and an ageing private • Obesity is a major public health challenge, general practitioner workforce may pose with adult and childhood obesity rates the future workforce challenges. highest in the EU. Binge drinking among adolescents also remains a concern. Recent • As a small country, Malta faces difficulties in initiatives addressing food provision in schools ensuring availability of new medicines. This and alcohol sales to minors aim to tackle is now a critical issue, with the government’s these risk factors. Socioeconomic inequalities list of approved medicines struggling to in health status and related risk factors keep up with innovation. The increased use persist and tackling health inequalities and of Managed Entry Agreements, biosimilars their causes is a new cross-sectoral political and clinical pathways, and protocols for the focus. evaluation of new medicines has contributed to improved access in recent years. Stronger • Malta spent 9.3 % of GDP on health care cross-border collaboration and policy options in 2017, which is slightly below the EU facilitating the use of generics and biosimilars, average (9.8 %). Reorienting services away as well as new models encouraging joint from hospital settings towards primary and procurement and price transparency, are outpatient care to improve efficiency and key strategies to further enhance access to enhance care for chronic conditions is a medicines. priority. Primary care is being strengthened through upskilling the workforce, building • New public capital investment has been new facilities and upgrading existing ones, made to upgrade medical equipment in and expanding the range of services. A hospitals and to build additional hospital reorientation of services to more cost-effective units to improve capacity for outpatient settings will help accommodate future services, mental health care and mother and projected increases in spending due to an child care. A new public-private partnership ageing population. aims to secure further capital investment to modernise hospitals and improve capacity, • Reported unmet needs for medical care in but careful monitoring is needed to ensure it Malta are generally low, but some evidence improves quality of care, while maintaining points to a higher impact on lower income equitable access and safeguarding health groups. A comprehensive benefit package system sustainability. is available free of charge; however, out-of- pocket spending is among the highest in the EU, due to private expenditure on primary

22 State of Health in the EU · Malta · Country Health Profile 2019 Key Sources

Azzopardi-Muscat N et al. (2017), Malta: health system OECD/EU (2018), Health at a Glance: Europe 2018 – review. Health Systems in Transition, 19(1): 1-137. State of Health in the EU Cycle. OECD Publishing, Paris, https://www.oecd.org/health/health-at-a-glance- europe-23056088.htm

References

ECDC (2017), ECDC country visit to Malta to discuss Government of Malta (2019), Diabetes shared care antimicrobial resistance issues. Mission report July 2017. programme overview. Valetta. European Centre for Disease Prevention and Control, Stockholm. IHME (2018), Global Health Data Exchange. IHME, Seattle. ECDC/WHO (2018), HIV/AIDS Surveillance in Europe 2018. Surveillance Report. European Centre for Disease Ministry for Health (2018), A Strategy and Action Plan Prevention and Control/ WHO – Regional Office for for the Prevention and Containment of Antimicrobial Europe, Stockholm. Resistance in Malta (2018–2025). Closed consultation, Valetta. European Commission (2016), Mapping the Use of European Structural and Investment Funds in Health in Ministry for Health (2019), Open Consultations, the 2007–2013 and 2014–2020 Programming Periods. Government of Malta, Valetta. Brussels, http://www.esifforhealth.eu/pdf/Mapping_ National Audit Office (2017), Performance Audit: Report_Final.pdf Outpatient Waiting at Mater Dei Hospital, Floriana. Council of the European Union (2019), Council Rechel B, Richardson E, McKee M, eds. (2018), The Recommendation on the 2019 National Reform organization and delivery of vaccination services in the Programme of Malta, http://data.consilium.europa.eu/ European Union. European Observatory on Health doc/document/ST-10171-2019-INIT/en/pdf Systems and Policies and European Commission, http:// European Commission (2019), Joint report on health care www.euro.who.int/__data/assets/pdf_file/0008/386684/ and long-term care systems and fiscal sustainability vaccination-report-eng.pdf?ua=1 – Country documents 2019 update. Institutional Paper Vassallo M, Borg A (2018), ESPN Thematic Report on 105. Brussels, https://ec.europa.eu/info/sites/info/files/ Inequalities in Access to Healthcare Malta 2018. economy-finance/ip105_en.pdf European Commission, Brussels. European Commission (DG ECFIN)-EPC (AWG) (2018), The 2018 Ageing Report – Economic and budgetary projections for the EU Member States (2016–2070), Institutional Paper 079. May 2018. Brussels, https:// ec.europa.eu/info/sites/info/files/economy-finance/ ip079_en.pdf

Country abbreviations

Austria AT Denmark DK Hungary HU Luxembourg LU Romania RO Belgium BE Estonia EE Iceland IS Malta MT Slovak SK Bulgaria BG Finland FI Ireland IE Netherlands NL Slovenia SI Croatia HR France FR Italy IT Norway NO Spain ES Cyprus CY Germany DE Latvia LV Poland PL Sweden SE Czechia CZ Greece EL Lithuania LT Portugal PT United Kingdom UK

State of Health in the EU · Malta · Country Health Profile 2019 23 State of Health in the EU Country Health Profile 2019

The Country Health Profiles are an important step in Each country profile provides a short synthesis of: the European Commission’s ongoing State of Health in the EU cycle of knowledge brokering, produced with the ·· health status in the country financial assistance of the European Union. The profiles ·· the determinants of health, focussing on behavioural are the result of joint work between the Organisation risk factors for Economic Co-operation and Development (OECD) and the European Observatory on Health Systems and ·· the organisation of the health system Policies, in cooperation with the European Commission. ·· the effectiveness, accessibility and resilience of the The concise, policy-relevant profiles are based on health system a transparent, consistent methodology, using both quantitative and qualitative data, yet flexibly adapted The Commission is complementing the key findings of to the context of each EU/EEA country. The aim is these country profiles with a Companion Report. to create a means for mutual learning and voluntary For more information see: ec.europa.eu/health/state exchange that can be used by policymakers and policy influencers alike.

Please cite this publication as: OECD/European Observatory on Health Systems and Policies (2019), Malta: Country Health Profile 2019, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.

ISBN 9789264718593 (PDF) Series: State of Health in the EU SSN 25227041 (online)