Country and population

Malta is the smallest country in the EU25 (315 km²), principally consisting of three inhabited islands: Malta (the largest), Gozo and Comino. Malta became a Republic in 1974 (Azzopardi Muscat & Dixon, 1999; Pace Asciak, Camilleri & Azzopardi Muscat, 2002) and a member of the EU in 2004. Malta’s population is estimated at around 405 200 (Pirjol, 2010). The proportion of the population aged 0–14 years fell from 19% in 2002 to 15.4% in 2008 and the proportion of the population aged 65 years and over is in 2008 around 14.4% (WHO Regional Office for Europe, 2010a).

Development and economy

Malta is divided into 68 local council districts where elections for local councils are held every three years. The national government is responsible for providing health care services. The Maltese Parliament is unicameral. A steady increase in GDP and health expenditure as a percentage of GDP has been observed in Malta, with GDP per capita of US$ 13 256 in 2004 (Pirjol, 2010). Total expenditure on health as a proportion of GDP was 8.5% in 2005. Between 1985 and 2007 Malta’s Human Development Index rose by 0.50% annually and from 0.809 to 0.902 in 2009. Malta has been ranked 34th out of 175 United Nations countries according to HDI (UNDP, 2010). The 6828 registered unemployed people in July 2010 decreased by 693 when compared to the corresponding month in 2009 (National Statistics Office Malta, 2010).

The adult illiteracy rate for the population aged 15 years and over in the year 2000 was 8% of the total population (Pace Asciak, Camilleri & Azzopardi Muscat, 2002). Based on 1995 census data, an estimated 50% of men and 44% of women have completed at least the secondary level of education (Pace Asciak, Camilleri & Azzopardi Muscat, 2002).

Population’s health

Life expectancy in males is 77 years and 82 years in females (2008). During the year 2008 there were 47 perinatal deaths reported to the National Mortality Registry, consisting of 26 fetal deaths and 21 early neonatal deaths. There were 34 infant deaths. These deaths do not include fetal deaths weighing less than 500 g. During the year 2008 there were 3243 deaths in residents: 1668 male deaths and 1575 female deaths. There has been a downward trend in mortality rate in Malta in the past 10 years. This trend is also reflected in mortality rates in those aged less than 65 years. The standardized mortality rate (SMR) in Malta is comparable to that of the EU15 (countries that joined the EU before May 2004) and lower than that of the new EU member states. Deaths due to diseases of the circulatory system, namely ischaemic heart disease, stroke and heart failure, are the leading causes of death accounting for 40% of all deaths. Despite a downward trend in mortality rates from ischaemic heart disease, rates are higher than the EU15 average. Diabetes mellitus is an important risk factor for ischaemic heart disease, and accounts for nearly 5% of all deaths. Neoplasms are the next commonest cause of death, accounting for 26% of all deaths. While the overall number of deaths is increasing, Malta’s SMR compares well with the EU15 and is better than that of the EU12 (i.e. the countries that were members in 1986) in all age groups and in those aged less than 65 years. However the average age at death due to neoplasms is 70 years, much younger than that for circulatory diseases. There were 298 deaths due to respiratory conditions accounting for 9.2% of all deaths. Mortality rates from traffic accidents and suicides show a predominance in the younger age groups but Malta fares better than both the EU15 and EU12 in this respect (Department of Health Information and Research, 2008).

There are 10.2 births/1000 population. The natural population growth rate has been declining, mainly because the crude birth rate is falling. There has also been a concomitant decrease in the total fertility rate to 1.5 in 2001 (Pace Asciak, Camilleri & Azzopardi Muscat, 2002).

In 2007 the rate of acute care hospital admissions was 10.7%, which is below EU15 level (European Hospital and Healthcare Federation, 2009).

Characteristics of the health care system

The health system in Malta is characterized by highly centralized structures. General taxation provides the main source of health care funding but the general trend until recently has been towards increasing the private share under the form of voluntary premiums or user charges. In Malta, due to the small size of the health market, the production of some highly specialized services is not financially viable. Consequently the Maltese government funds overseas treatment for conditions necessitating such highly specialized care (McKee, MacLehose & Nolte, 2004). The hospital sector dominates the health expenditure of the nation and absorbs the major part of the health budget. In Malta the number of hospital beds almost doubled after 2004. The total number of hospital beds in 2001 was 1950 and 3192 in 2007, which represents 63.7% difference (European Hospital and Healthcare Federation, 2009).

While health care practitioners in Malta are allowed to exercise their profession in both public and private health care services, the government of Malta is not responsible in any way for any treatment or care given to EU citizens in private hospitals or health centres, or by practitioners of any sort in their private capacity. Health care in public services is generally free at the point of use. A patient may access public health care services directly on presentation of the health card. The patient will have to pay for the cost of any prosthesis and any follow-up prescribed medication, excluding medication prescribed for the first three days after discharge from hospital. Only acute emergency dental care is offered free of charge in hospital outpatient and health centres, and to a limited extent. Most dental care is provided in private dental clinics at the patient’s own expense. All drugs used in inpatient treatment and for the first three days after discharge are free of charge for the patient. Otherwise, prescribed drugs must be paid for in full.

Primary care is provided by the state health services and by private family physicians. These two primary care systems function independently of one another. It has been estimated that the private sector accounts for about two-thirds of the workload in primary care. Of respondents to a recent population survey, 80% confirmed that they use a private family doctor as their primary provider of health care (Soler et al., 2009). The state-run primary care system covers family medicine, community care, immunization and the school health service. These services are mainly delivered and coordinated from eight government health centres that cover an extensive range of preventive, curative and rehabilitative services (Ministry of Health the Elderly and Community Care, 2008). There are company doctors working in Malta as well. Company doctors are hired by companies mainly to verify the illness of employees who report sick by visiting them at home. The role of company doctors is mainly verification of sickness, since in Malta a sick leave certificate is mandatory from the first day of absence. Increasingly, the role of company doctors involves important involvement in occupational medicine and health and safety at the workplace. Company doctors are an important provider of primary medical care for employees who report sick from work. Services in the private sector are open to all those who can afford to pay the fees, and also to a growing sector of the population which has private health insurance (Sammut, 2000).

Table A19.1 compares the development of health resources and utilization in Malta with the EU averages.

Table A19.1

Development of health care resources and utilization.

2.1. Primary care governance

In 2003, with Malta’s entry into the EU and a reform of the health care professions act, Family Medicine became a separate medical speciality (Malta College of Family Doctors, 2006).

The first government health centres were established in 1979. Today family physician services in Malta are provided by about 150 full-time equivalent family physicians, who work in private practice and 57 full-time equivalent family physicians, who work in government practice (2009). There is no patient registration in Malta and family physicians have no formal patient lists. Eighty per cent of patients report that they have one private family doctor as their main primary care provider. Only 4% report that a health centre doctor is their first provider of choice, but 13% report using various doctors depending on the particular need (Soler et al., 2009; Sciortino, 2010). The publicly employed family physicians have a limited gatekeeping role. For instance, patients can bypass the family physician and visit a specialist or other health providers without referral. In addition, the family practice services are limited. For instance, a community-based internal medicine specialist checks out the range of chronic diseases, and family physicians have limited prescribing rights as against other specialists. The publicly funded family physicians are usually visited free of charge in emergency situations or for routine cases, while for most difficult situations patients seek the help of the private family physicians or specialists (Department of Health Information and Research Strategy and Sustainability Division MfSP, 2010).

2.2. Economic conditions of primary care

There are no official statistics available regarding the total expenditure on primary care. The hospital sector dominates the health expenditure of the nation and absorbs a major part of the health budget. Over the years it has grown incrementally to accommodate increased demand and developments in technology. A precise estimate of the proportion spent on primary care is difficult to make as secondary care physicians on a part-time basis provide certain services at health centres. Resource allocation is carried out by the Ministry of Finance, the Ministry for Health and its four subsidiary divisions responsible for Health Care Services, Public Health Regulation, Resources and Support, and Strategy and Sustainability. Total expenditure on health as a percentage of GDP was 7.7% in 2008 (see Table A19.1).

In Malta, the government provides a comprehensive free health service to all residents. This health service is funded from general taxation. All residents have access to preventive, investigative, curative and rehabilitative services in government health centres and hospitals (Exposure jobs, 2010). Providers in health centres are paid by salary. Annual earnings of a private family physician range from €25 000 to €75 000. Few family doctors would earn more than €50 000 a year, but some (a very small minority) would earn more than €60 000. Annual earnings of hospital doctors are different in different private hospitals/practices or specialist consultancy services (Reed Specialist Recruitment, 2009). There are no data available comparing the incomes between primary and secondary care providers.

2.3. Primary care workforce development

Family physicians work exclusively in primary care. Specialist training in family medicine in Malta takes place under the auspices of the government’s Primary Health Department, with the Malta College of Family Doctors responsible for ensuring the quality of academic training and assessment. As a result of Malta’s accession to the EU in 2004, family medicine was accepted as a specialty and a three-year “Specialist Training Programme in Family Medicine – Malta” was drawn up by the Malta College of Family Doctors (MCFD) in 2005 and approved by the Ministry of Health’s Specialist Accreditation Committee in 2006 (Sammut et al., 2006). The “Curriculum for Specialist Training in Family Medicine for Malta” was published in 2009 by the MCFD’s Curriculum Board. The programme comprised 29 family physician trainees in 2010: 12 who entered the programme in 2008, 6 in 2009 and another 11 in 2010. In 2010 the first cohort of 11 trainees has undertaken the summative examination at the end of specialist training, which is being delivered by the MCFD with the collaboration of the UK Royal College of Family physicians.

The Health Care Services Standards Directorate (DHCSS) was established in September 2007. This is a new Directorate within the Department of Public Health Regulation. The licensing process which was previously within the remit of the Department of Institutional Health is now part of the responsibility of DHCSS but its breadth and scope have expanded with the added responsibilities specific to this new regulatory Directorate’s portfolio. The principal purpose of the DHCSS is to achieve improvement in the quality of care and ensure patient safety through regulation. To achieve the main objective of improving health care services in the Maltese islands, the DHCSS formulates and recommends national standards for hospital services, homes for older people and community care with the active participation of the relevant stakeholders and interested parties. It promotes a quality and patient safety culture within public and private service providers, inspects and licences hospital services, clinics, community and primary care services, homes for older people, blood establishments, hospital blood banks and tissue establishments. The DHCSS also monitors hospital and medical services’ clinical performance and outcome indicators as part of the health care licensing and regulatory mechanisms, and enforces health care laws and regulation through advice, education, persuasion and legal action if necessary

The total number of doctors registered in Malta is around 1150. This includes 60 foreign physicians/surgeons engaged by the government to occupy certain posts within the Department of Health. Eighty-one per cent of listed doctors are males and 19 per cent are females. One thousand and twenty doctors are registered as Malta residents and 130 as overseas residents. Out of the 1020 doctors in Malta, 560 are employed by the government (Sciortino, 2010). The rest are either in private practice or retired.

The Medical Association of Malta has warned that doctors are finding it increasingly difficult to cope with a growing demand for their services and has appealed to the authorities to be more sensitive to the needs of patients (Medical Association of Malta, 2007). There is a shortage of nurses and pharmacists as well (Ministry of Health the Elderly and Community Care, 2006) and a call was made for 200 nurses and 30 pharmacists. Most (96%) patients find it easy to reach and gain access to family physicians (TNS Opinion & Social, 2007). The Primary Health Care Department has to deal with a shortage of health care manpower, although towards the end of 2007 the nursing vacancies were all filled. There was also some improvement in the number of family physicians in 2010 when 11 family physicians trainees completed the Specialist Training Programme in Family Medicine, which they started in 2007. This intake of about a dozen trainees a year is expected to continue in the medium to long term.

3.1. Access to primary care services

Free access to comprehensive primary care services is possible by visiting a health centre. The health centres are the hub of the primary care services provided by the government. Besides the family physician and nursing services, various specialized health services are provided. These include immunization, speech therapy, dental services, antenatal and postnatal clinics, well baby clinics, diabetes clinics and paediatric clinics. At present there are eight health centres. Floriana Health Centre has two satellites, Gzira Health Centre and Qormi Health Centre. Paola Health Centre has one satellite, Cospicua Health Centre. Mosta Health Centre has one satellite, Rabat Health Centre. The public is requested to attend the health centre that serves his/her locality of residence. The Director is responsible for the provision of services at primary care level by organizing and coordinating all functions relating to health centres. The Director ensures the development and maintenance of an accessible, integrated continuum of primary care services. S/he plays a leading role in the development and implementation of the strategic plan for the strengthening of primary care. The Director ensures that services within the Directorate are operating in line with the Ministry’s policy, strategy, regulations and standards. The Director also ensures that services are delivered according to the needs of the user and that users’ rights are respected.

In the public service it is only possible to see a family physician, gynaecologist, podologist, speech-language pathologist, or practice and immunization nurse without a referral. For physiotherapists, optometrists, the diabetes clinic, the well baby clinic, the medical consultant and the home care nurse, a referral is required.

In the private sector, direct access for the patient is possible as the costs of the visit are paid directly to various professionals, such as the gynaecologist/ obstetrician, paediatrician, specialist in internal medicine, ophthalmologist, ENT specialist, cardiologist, neurologist, surgeon, occupational therapist, physiotherapist, psychologist and speech-language pathologist.

The opening hours for health centres varies, with some opening from 08:00 to 20:00 hours with family medicine services stopping at 17:00 and limited openings at weekends, while others are open for 24 hours, with family medicine services switched over to “emergencies only” between 17:00 hours and 08:00 hours during week days and from 13:00 hours on Saturday to 08:00 hours the following Monday.

Figure A19.1 shows the extent to which patients have access to organizational arrangements in primary care practices or centres.

Fig. A19.1

The extent to which organizational arrangements commonly exist in primary care practices or primary care centres.

3.2. Continuity of primary care services

Continuity of care in the private family medicine sector is good (Soler et al., 2009). In contrast there is poor continuity of care provided by the state family doctor services. As there is no patient registration system in Malta, a client can walk into a health centre at any time to see the doctor who happens to be on duty. Moreover, as most clients attend for minor problems, entries are not always made in the health centre medical records that were introduced in 1997. Medical record keeping in private practice cannot be said to be optimal and formal registration is non-existent (Sammut, 2000). The fact that people shop around between family physicians, specialists and health centres is a fault of the system (Mallia, 2001). The main weaknesses that need to be addressed are: the lack of continuity of care, the need for a stronger doctor–patient relationship, the duplication of resources, the lack of a robust patient record and IT system, limited access by family doctors to state facilities, the lack of a multidisciplinary approach to primary care, the paucity of investment in the sector and client abuse of the system (Ministry for Social Policy (Health, Elderly and Community Care) 2009).

3.3. Coordination of primary care

The government’s health centre system works side by side with a thriving private sector and many residents opt for the services of private family physicians and specialists who work in the primary care setting. Most people (almost 85%) have only one family doctor. This relationship was of five years or more duration in most cases (75%) (Soler et al., 2009).

Although coordination between primary care services provided by the public and private sectors is limited, private family doctors do have some access to investigative services provided by government health centres (certain blood and urine tests, ECGs and chest X-rays). Private family doctors may also refer patients for most services provided by the various clinics held in government health centres. Access to these services for private family doctors and their patients has been recently increased. Fig. A19.2 shows how primary care practices are shared between medical professionals in the private sector.

Fig. A19.2

Shared practice.

While patients can self-refer themselves to hospital specialists working in the private sector, official referrals from public or private family physicians are required for specialist services in public hospitals. The issue of discharge letters from specialists to family physicians is mandatory following inpatient care in government hospitals; however such letters often reach the family physicians some time after the patient has been discharged.

3.4. Comprehensiveness of primary care services

Private family doctors are able to provide a broad range of services, including minor surgery, imaging modalities and access to private specialist services. These services have been improved by recent courses for family doctors with special interests in such areas as women’s health, diagnostic ultrasound, minor surgery and others. The family medicine and nursing services are supplemented by various specialized services that include antenatal and postnatal clinics, well baby clinics, immunization clinics, gynaecology clinics, diabetes clinics, medical consultant clinics, ophthalmic clinics, psychiatric clinics, podiatric clinics, physiotherapy clinics and speech-language pathology clinics. Community nursing and midwifery services are provided by the Malta Memorial District Nursing Association (MMDNA) on a contract basis.

Table A19.2 lists examples of GPs’ involvement in the delivery of various primary care services.

Table A19.2

GPs’ involvement in delivery of various primary care services.

4.1. Quality of primary care

Immunization against diphtheria, tetanus and polio is obligatory. Immunization against pertussis is also offered though not obligatory. Immunization rates are believed to be very high, although information about the number of immunizations given in private practice is incomplete. Diphtheria and polio are considered to be diseases that have been eliminated in the local population. The last recorded case of diphtheria occurred in 1969, while that of polio occurred in 1964. The continued existence of pertussis cases is the price Malta is paying for low immunization rates against this disease. Measles epidemics used to occur every four years in the Maltese islands. An intensive immunization campaign in 1989 not only aborted the expected 1990 epidemic, but also enhanced the practice of immunization against measles as a routine measure.

In the first national health interview survey in Malta (HIS) 24.9% participants answered that they have a long-standing illness or health problem: 18.7% allergy (except asthma), 17.2% high blood pressure, 8.9% high cholesterol, 8.0% chronic bronchitis, 7.26% asthma and 7.1% diabetes mellitus. Data about how often these patients are reviewed in primary care are scarce. About 89% of asthma patients are reviewed at least once a year and 74% every six months by their family physicians (Pace Asciak et al., 2003).

4.2. Efficiency of primary care

The analyses of performance of state family medicine services in 2006 shows that there were 357 100 episodes of care in health centres, 197 100 episodes in district clinics, 13 200 home visits by day and 2019 home visits by night. The total number of health centre family physician encounters in 2006 was 569 429 (Ministry of Health the Elderly and Community Care, 2006).

Patients who were asked “Thinking of the last time you consulted a Family or Health Centre or Casualty or Outpatients doctor, within the past 12 months, where or how did you consult the doctor?” answered that they consulted the doctor’s private clinic in 40.0% of attendances, private hospital/clinic in 5.76%, a health centre in 8.65%, the casualty/outpatients department in 4.55%, while 15.77% consulted the doctor through home visits and 0.7% consulted by telephone (Pace Asciak et al., 2003)