Malta Independent interviews Health Minister - 24/8/2003

Minister keeps proposals secret but promises free services to low-income earners

Karl Schembri

Health Minister Louis Deguara is adamant, he is keeping his health service reforms secret.

“After all, they’re only proposals. I still need the Cabinet’s approval,” he says. But behind them is not one but three Ministers; he is flanked by Finance Minister John Dalli and Social Policy Minister Lawrence Gonzi.

Dr Deguara hit the headlines last week when he said the health system is “unsustainable” and the situation is “alarming”. I ask him how unsustainable and alarming the situation is but he immediately points out that the situation has been getting worse over the years.

“I am astonished how everyone is latching on to this story about the unsustainability of the health system now because of a front-page report, when I have been saying this since 1995,” Dr Deguara says. “I’ve learnt that nobody reads articles. I had said exactly the same things in an article three weeks before and nobody noticed then when there was a front-page report everyone woke up and interpreted it as they pleased.

“I can’t understand Alternattiva Demokratika, for example, which said that ‘any reform in this sector should eliminate waste and abuse of public money but should not affect in a negative manner the quality of life of ordinary citizens who are dependent on the national health service for their needs’. When I wrote my article I said that any measure we take will aim at guaranteeing a viable system for all those who can’t afford to pay for health services. Even in Parliament I’ve said it many times that the way our health system is developing is not really reflecting our values of solidarity and subsidiarity. Why? In 1995 I said we were spending Lm6 million on medicine and disposables and now we’re spending Lm18 million. If you look at the way money is spent on medicine you’ll find that the means-tested drugs cost Lm1.92 million in 1995 and today they cost Lm2 million - so the substantial increase in expenses was for those medicines that are not means-tested.”

The point everyone misses, according to Dr Deguara, is that the problem is not really waste and abuses but rather the expense of keeping up with the increasing range of health services.

“Everyone thinks the expenses have soared because of abuses and waste,” Dr Deguara says. “Even those who write in newspapers have no idea that the price of medicines increase by an average of 12 per cent every year world-wide. Moreover, we’ve increased so many health services that most of our expenditure is on these new services. If everyone thinks that our first priority is to curb abuses and waste then everyone is mistaken, they understand nothing. Even if we had zero per cent wastage, you would still be unable to cope with the yearly soaring cost of drugs. That on its own does not justify the rise over the last seven years; there are the new services which are costly. Having said that it’s definitely a good thing that we’re offering these services because one can see the results. In cardiology for example, while before we used to send 100 patients abroad every year for a bypass, now we are doing an average of 14 a week over here. We used to send 100 people for angioplasty abroad, now some 2,000 angioplasty operations a year are done here, but of course every angioplasty costs money and raises expenses.”

Then there are some strange figures the minister cites from studies conducted by the health department, illustrating the habits of the Maltese. One-third of the population goes to the casualty department when they have a problem; health centres get 1.1 million clients a year, which means that every Maltese person goes to a health centre three times a year. Given that 75 per cent of the population at primary care level go to private clinics, this means that there are around 100,000 individuals who attend health centres 1.1 million times a year.

“Isn’t that an abuse? Isn’t it an abuse to have 400,000 people visiting the out-patients department every year? That means that every Maltese goes to out-patients at least once a year. Now if 25 per cent of the Maltese goes to out-patients, that means that every client goes there four times a year. Isn’t this an abuse of the system? Isn’t it high time we do something about it?”

As regards quality, the fact is that Malta ranks fifth in the World Health Organisation’s classification of public health services world-wide, and Dr Deguara says he wants to keep the same standards, only that costs have to come into the equation.

“We’re about to publish the first-ever report on the health of the Maltese people and it is very favourable, but we’re getting there at a cost, and that is what I’m saying. The system we have today cannot cope if we want to keep these levels. We have to start anew.”

By way of defence against those who said the minister is accountable for the situation which must have deteriorated right before his eyes, Dr Deguara says that he has been talking about the unsustainability of the system ever since he was appointed minister. But what did he do about it apart from talking?

“Before taking any measures... we’ve passed through the stage when the medical profession kept developing... I remember a particular Health Minister buying equipment to open a sleep lab which we haven’t opened yet because we don’t have trained people to operate it. We’ll open it in the coming weeks, three years later. There were people who wanted breast cancer screening without having trained staff to do it. These last three years served to get people qualified to offer this service.

“What did I do? We have a record number of employees and an information system which enables you to make good decisions. The boost in the government’s information technology helps us make informed decisions. Now we’ve reached certain conclusions in view of the situation. As a Health Department we have the information at hand and we know the decisions that need to be taken. Now we have to propose them to see whether they are acceptable or not.”

So are you saying that your government has been ‘studying’ the situation since 1987?

“I wasn’t a Minister in 1987 and I’m being accused that I’ve left the health system to deteriorate, which is not at all true. One has to understand it is not a question of deterioration, it is a question of not coping financially with the expansion of health services. Everyone wants a health centre in his locality without knowing what it entails. Does anybody know that to train a nurse in the BSc course costs us Lm10,000? We’re after quality rather than quantity, but is anyone aware of the costs? Does it not make sense to take precautions today to be able to cope? That is what we’ve been doing.”

What are your plans?

“I’m not saying people will have to pay for health services because there are many measures we can take. If you think you asked me a loaded question to get me to talk about my proposals you’re very far from an answer.”

I don’t think it’s such a bad idea to tell us what your proposals are.

“No I can’t tell you. Why should I prefer you to others?”

It has nothing to do with me, it’s in the public interest.

“These are only proposals. Once they are accepted we start discussing them with the people concerned.”

Accepted by whom?

“By the Cabinet of course. If it is a policy decision isn’t it obvious that the Cabinet has to approve it? Mind you there is an ad hoc committee made of representatives from the Finance Social Policy and Health ministries behind these proposals; it’s not just a health ministry thing. I didn’t just wake up and write an article. One has to look at it from different angles.”

The Minister rules out wage increases for staff at St Luke’s Hospital, which is costing the government some Lm300,000 a week to run. He says that although he agrees with the unions, he cannot responsibly raise wages at the same time he says the situation is unsustainable.

And problems are destined to multiply by four when the Mater Dei Hospital will be up and running: it will cost Lm1.2 million a week just to keep it going.

“I have always said that running Mater Dei with today’s practices is not possible,” the minister says. “We are embarking on new management systems that will make the services more efficient. How many people grumble that we don’t have enough nurses? Is it the number or the deployment? Can’t we get better services with the number of nurses we have today? Nurses are concerned that whatever system you introduce won’t affect their wages. So if we keep the same wages but change the system according to the needs, such as working hours, then I don’t think there should be any objections, there is agreement on these changes. But in the meantime people should stop pointing fingers and shooting opinions without understanding anything.”

You said you have studies and figures at hand. Will you make them public?

“I’ll make them public at the right moment.”

They might help the public understand you.

“No. The important thing is that people don’t just jump to the conclusions they deem fit and talk nonsense. It would be better if people ask questions before firing. Everyone thinks that the system is unsustainable because of abuses and waste and that if we curb those we would solve the problem. It is not true.”

Do you consider high income earners who use the public health system to be abusing the system?

“Until today that is not an abuse because as long as they pay national insurance like everyone else then they have the right to the services.”

Who qualifies for free health care from the means test you’re proposing?

“You’ll know after I get the Cabinet’s approval.”

But will you introduce a means test?

“There are many means tests and measures we can introduce.”

Do you know how much the means test itself will cost?

“What do you mean?”

Do you know whether the means test itself is financially viable?

“At this point we’re only talking about principles rather than how to implement them. So you’ll have to wait until Cabinet convenes.”

Can you tell me your principles about private health insurance?

“We’re committed to encourage private health insurances. One of the earliest measures we introduced was to remove tax from health insurances. I think private insurances should be encouraged because policy holders would ease the burden on the public service. What is happening today is the direct opposite. Whoever has private insurance and goes to St Luke’s is paid for going to a public hospital and the government gets nothing. Private insurances should be encouraging clients to get private health care not the other way round.

“What is sure in these reforms is that we will definitely help all those who are unable to pay for health services, they will keep getting health services for free, that’s for sure. When we opposed Labour’s introduction of a 50c charge on drugs we weren’t really opposing the charge but the fact that it was imposed across the board when not all the citizens should be paying it; single parents, pensioners etc. You have to make a distinction if you really believe in the value of solidarity, between those who can and those who cannot pay. We won’t propose measures encouraging everyone to take private insurance because it doesn’t make sense, or if we do then the government will pay for those who cannot afford it.

Do you have any target dates for your proposals?


Will you give me your studies for publication?

“Forget it.”

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