With a population equivalent to that of a small city, Malta has done better
than most in ensuring equitable health care. But chronic funding shortages mean
the country’s health system requires a delicate balancing act-one which EU
requirements threaten to upset. Stephen Pincock reports.
The Maltese archipelago, a few sun-baked specks in a narrow stretch of the
Mediterranean sea, was the smallest nation to join the EU in May, 2004, by quite
some margin. The three islands that comprise the country-Malta, Gozo, and tiny
Comino-are home to just under 400000 people. The largest of the group, Malta, is
only 27 km across at its longest point.
As a small island nation, Malta faces particular challenges when it comes to
sustaining a health-care system-total physician numbers are so small that the
loss of two radiologists, for example, can be a difficult blow. The failings of
a single acute care hospital are felt by the entire nation.
Despite these difficulties, Malta has managed, until now, to operate a system
that works. But looking into the future the situation is less certain, as harsh
economic realities begin to cut more deeply, and EU requirements, such as the
working-time directive, threaten to upset a delicate balance.
Life on a small island
Throughout history, Malta’s strategic position has made it a prime target for
occupation by hostile invaders.
With Tunisia about 300 km away to the south, and Sicily 93 km to the north,
it has been occupied over the years by Phoenicians, Carthaginians, Romans,
Arabs, Normans, the Knights of the Order of St John, French, and British. It was
not until 1964 that it gained independence from Britain, a process of separation
that it completed a decade later by becoming a republic.
The capital city, Valletta, reflects this imperial procession in its
architecture and the offices of the Maltese Ministry of Health, the Elderly, and
Community Care are a prime example. They are housed in a grand limestone
building that was erected to serve as the courts of justice in the eighteenth
century, when the Knights of St John ruled the island.
The order of St John, also known as the Knights Hospitallers, played an
important role in the early development of Malta’s hospital system. Although
hospitals had existed on the island since the fourteenth century, it was during
the period of the knights’ rule that development picked up pace. In 1676, they
also established the first medical school-although it wasn’t until the British
arrived in 1815 that hospitals were brought together under a single system.
For the past 25 years, the country has operated a statutory health-care
system that is funded via general taxation, and is free at the point of use.
This equitable system-Malta’s miniature scale means problems of access to health
care are almost non-existent-nevertheless faces a chronic lack of funds.
Alongside the state-run system is a flourishing private health sector,
providing primary and secondary care for which the Maltese people seem willing
to pay. Private health spending in Malta accounts for around 30 of total health
«In primary health care, patients prefer to go to a private GP and pay a fee,
but they have the assurance that if they need an urgent GP at night and they don
‘t find their own, there’s a public-health doctor available», says John Cachia,
the health ministry’s Director for Institutional Health.
Overall, health-care expenditure in Malta currently runs at about 9 of GDP,
including capital expenditure for a new hospital-and is rising fast. As the cost
of practising medicine increases, the Maltese economy is struggling to keep up.
«One of the biggest challenges we’re facing is a very rapidly increasing
expenditure on medicines and medical devices», says Natasha Azzopardi Muscat,
director of European Union and International Affairs within the health ministry.
«The Maltese people are no fools when it comes to requesting the latest
technology and medicines. The fact that English is so widely spoken means that
people have access to all the UK and American internet literature-nowadays they
come to visit their doctor knowing exactly what they want.»
Oxford Cartographers, 2005
To some extent this problem has been brought to the fore by the country’s
accession to the EU, Azzopardi Muscat says. Now Malta has to take on a host of
EU obligations in this sector. «It’s going to mean better medicines for Maltese
people because a lot of medicines of possibly dubious quality will now be wiped
off the market, but at an increasing cost to the exchequer», she says.
Waiting lists for surgery in some specialties are already long, and Malta’s
macroeconomic obligations with regard to EU accession criteria mean the chances
of increased state expenditure are slim to non-existent. Something clearly needs
to budge. The questions for Malta are what, when, and how?
View from the hospital
Among the most spectacular views of Malta is that from the ramparts of the
medieval capital of Mdina, whose baroque cathedral, bastions, and palaces are
positioned on high ground inland from Valletta.
From its high stone walls, the Mediterranean is visible just a few miles in
the distance. Between Mdina and the coast, another major landmark is taking its
place in the landscape-in the form of a new acute-care research and teaching
What might be a routine occurrence in larger economies is a major event in
Malta. The island currently has one major acute-care hospital-St Luke’s-which
has 850 beds. There are another 58 beds in Sir Paul Boffa hospital, which
specialises in oncology and dermatology, 563 psychiatric beds at Mount Carmel
Hospital, and 60 beds for geriatric patients at Zammitt Clapp Hospital. On Gozo,
the Gozo General Hospital has 259 short-stay and long-stay beds.
These places are supplemented by less than 200 beds available in three
Walking around the shell of the large new site, it’s possible to believe
Malta’s claim that the ё300 million facility is the biggest medical project in
Europe. On the day I visit, the local television news is filming too. There’s a
great deal of public interest in what the government is building to replace St
Luke’s, which was constructed in the 1930s and commissioned after World War II.
Since the 1950s and 1960s, investment into maintaining and developing St Luke
‘s lagged behind requirements. Amenities that might be taken for granted in a
modern hospital environment are missing.
Piped oxygen, for example, is only available in certain areas, and when the
hospital needed to install a magnetic resonance imager, it had to put it in a
demountable building attached to the present building because there was no room.
«It’s a portable building styled into an MRI unit, and now we have a service»,
says Kenneth Grech.
The question of how to improve the inadequate resources of the hospital has
been rumbling for decades. First, in the 1970s, St Luke’s underwent a fairly
large expansion when an extension was built to house 300 beds.
Then, in the early 1990s, the government at the time took a decision to build
a 400-bed hospital to focus on specialties chosen for their relevance to the
Maltese environment-such as cardiovascular disease, diabetes, renal disease,
obstetrics and gynaecology. At that time, the government’s strategy was to have
the new hospital operate alongside St Luke’s.
But doctors had always been opposed to the idea of a split site for acute
services, feeling that those who worked in the new facility would be considered
the elite. So the medical profession had a major role in the decision taken in
1997 to expand the new build to integrate all of the acute care facilities for
the island, and to decommission St Luke’s completely.
Even once that decision had been made, the road to completion of the new
hospital has been far from smooth. A legal dispute over the fairness of the way
that the contract to supply medical equipment dragged on for months, and other
delays mean the new opening date is scheduled for July 1, 2007-10 years after
the original decision was made to build the facility.
But controversy continues to boil in parliament and the media over the
project. In November, an opposition vote of no-confidence in the government over
the way the project had been handled was defeated by 27 votes to 31.
One of the main bones of contention remains the project’s budget-and how the
Maltese economy will cope. As an opinion article in The Times of Malta said in
November, «The country is still paying way too much for the new Mater Dei
Hospital. We are now talking in terms of Lm145 5 million to be paid to Skanska
[the contractor] and an additional Lm30 million to Lm40 million for the supply
of medical equipment and logistics.»
«What started as an exciting project in the early Nineties to create a
specialised hospital then estimated to cost around Lm50 million has now turned
into a monster, which is not only costing the country a fortune, but is also
eating into taxpayers’ pockets to unacceptable levels.»
As Malta begins to adopt EU policies, working conditions for health-service
staff are facing major changes. To start with, the European working time
directives threaten to place an extra burden on a system that has relied on
having room to manoeuvre in order to get by with its limited pool of physicians.
«The only way we manage to run our system is by ensuring flexibility», says
Azzopardi Muscat from the health ministry. That is why the government, like
others across Europe, supports the retention of a clause that allows staff to
opt out of the requirements.
«We have a strong position on retaining the opt-out … because it will be
impossible to run our hospitals if we don’t. We are also very concerned by the
new proposal to introduce a 65 h weekly cap-a rigid cap will constrain the
flexibility that we’ve relied on so very, very heavily.»
The doctors’ union-the Maltese Medical Association (MMA)-is also in favour of
retaining the opt-out clause, although its reasons for doing so may be
In the association’s modest office in a non-descript building, MMA’s general
secretary, Martin Balzan, says that doctors’ salaries are so low in Malta (a
consultant’s gross income is 12000 Maltese Lira, for example) that consultants
boost their incomes by working in private practice. But junior doctors need to
work longer hours to boost their income.
«We have a low basic salary and overtime rates are 150», he says. «Junior
doctors don’t have much access to working in private practice [to supplement
their salaries], so the way they complement low basic pay is by working
overtime. Overall the system works. If the opt-outs come along, we are afraid
the system might collapse, you know?»
But European directives are not the only change afoot for medical practice in
Malta. The government wants to shake-up working arrangements across the service,
in large part to improve efficiency.
The ministry recently produced a policy document outlining proposals for
reforming working arrangements and presented it to the relevant unions, but hasn
‘t yet made the details public.
«If you look at the document, you wouldn’t think there was much in it, but
the implications behind the changes we want to introduce are huge for the way
Malta works», says Cachia. «At the moment, [doctors] work very much on their own
and we want them to work more as an organisation. We have very high calibre
well-performing clinicians who work in isolation, and who don’t feel part of the
organisation. I think the new work practices are trying to bring people to feel
they are part of the organisation, accountable to the organisation, and have to
work within the parameters of the organisation.»
When The Lancet spoke to him in November, Cachia said the ministry had
already heard informally from the union that it was going to be extremely
difficult to come to some kind of agreement. Indeed, in early December, the
doctors’ union publicly denounced the proposals, saying they showed an absolute
lack of respect toward the medical profession, and saying the document could not
form the basis for further discussions.
The ministry has good reason to tread carefully around the MMA. Industrial
relations in the Maltese medical system can be strained as the unions are strong
and can be militant at times. «I deal with some union issue within the hospital
«, says Kenneth Grech from St Luke’s. «Not on a daily basis, but at least a
couple of times a week.»
In 1977, a 10-year doctors’ dispute was triggered when the government at the
time amended legislation governing medical licensing. A partial strike triggered
the government to ban disputing physicians from working in the state health
system, and then to forbid them from working only in the private sector. The
dispute led many doctors to leave the island, and saw the health service run
mostly by foreign doctors. It was only resolved in 1987 when a change in
government reinstated the barred doctors and amended governing legislation.
As the European Observatory on Health Care Systems reported in 1999, «the
scars remain very deep, resulting in a situation where successive governments
are very cautious when dealing with doctors».
Echoes of empire
For a visitor, the reverberations from 150 years of British occupation are
plain to see in many aspects of Maltese life and culture. The telephone boxes
are red like those in the UK, for example, and although Maltese-a language with
Semitic roots-is the official tongue, almost everyone speaks English.
The British have also left their mark on the Maltese diet-bacon and eggs for
breakfast and afternoon tea are both commonplace. «If you’ll allow me the
comment, there has been an Anglicisation of the traditional Mediterranean diet»,
says Kenneth Grech, chief executive of St Luke’s. «I think the UK and US have
had a major impact on the Maltese diet.»
Although not all of the blame can be laid in the laps of the now departed
British, perhaps that dietary «contamination» is one explanation for the obesity
and related conditions that are a major problem in Malta. The country has one of
the world’s highest rates of childhood obesity, and has a high incidence of
diabetes. Ischaemic heart disease killed 172 people per 100000 in Malta in 2002,
compared to the EU average of 97 per 100000.
«Over 60 of people here are obese and as a result of that the prevalence of
hypertension is high and the prevalence of diabetes is high», says Martin
Balzan, a respiratory physician and secretary of the MMA. «This prevalence is
more likely to be linked to our lifestyle than our genetic make-up.»
Despite all that, and the restricted resources available for health care, the
current situation is that the Maltese people enjoy quite a good state of
health-at least if you go by the classical indicators of life expectancy at
birth and life expectancy at 60 years of age.
«We do well even for newer parameters», says John Cachia. «WHO has recently
reported on risk of death between ages 15 and 59, and Malta stands 4th lowest
risk in the world for men and 19th lowest for women. I think that is quite a
remarkable feat because it gives you an idea of the stock of people who are
going to be your elderly in coming years.»
One of Malta’s major archaeological treasures are the so-called fat lady
statues, such as the enormous example discovered in the megalithic temple
complex at Tarxien, which are thought to represent a goddess of fertility
worshipped by the ancient Maltese.
Fertility is no longer so prized in Malta. The country’s fertility rate is
declining at one of the fastest rates in Europe as women postpone childbearing
The combination of a good life-expectancy and falling fertility rates could
only mean one thing for Malta-an ageing population that offers another challenge
for the cash-strapped health-care system.
«If you ask me what the biggest challenge for the health-care system in Malta
is going to be-apart from sustainability of health care in terms of resource
requirements-it’s going to be care of the elderly in the future», says Cachia.
«How are we going to care for our elderly? Because of our ‘success’ they are
very healthy stock, they’re on a very good footing.»
Finding a solution
Even if the Maltese government does achieve a dИtente with medical
professions, and between them they come up with greater efficiencies, the
reality is that increased drug and device costs, an ageing population, and a
high incidence of chronic conditions like obesity and diabetes are going to put
enormous financial pressure on the health system.
The question for Malta is how to sustain their high quality system in the
face of these spiralling costs.
The Malta Council for Economic and Social Development is already discussing
possible future scenarios for changing the way the system is financed-such as
introducing a social insurance system.
«We are envisaging that possibly some kind of changes may take place in
coming years, but it still isn’t clear which is the best solution for Malta»,
says Azzopardi Muscat. «Malta is facing challenges in its macroeconomics.
Basically, in order to meet the EU convergence criteria, we’ve got a pretty
strict line to toe. Increasing public sector financing is not really an option
for Malta to consider at the moment.»
The Lancet 01.2005