Article in the Lancet on Maltese Health Care System - 12/1/2005

World Report

Maltese crossroads

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 400 000 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.

Oxford Cartographers, 2005

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 expenditure.

"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."

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 hospital.

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 private hospitals.

Walking around the shell of the large new site, it's possible to believe Malta's claim that the £300 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."

Delicate negotiations

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 different.

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 12 000 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 100 000 in Malta in 2002, compared to the EU average of 97 per 100 000.

"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 and childrearing.

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 détente 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."
Stephen Pincock

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