Introduction

The healthcare sector is extremely broad and diverse. It is highly regulated and socially very sensitive since it deals with a very special commodity: life.

Good health service means the delivery of effective, safe, quality care to those who need it, when needed and with minimal waste.1 Key determinants for an effective health service delivery are primarily health facilities (the Providers) and finance (the Payers) operating under a sound jurisdiction. These are in turn dependent on the availability of resources and support services. Healthcare delivery is an important priority for Malta. The substantial investment in the healthcare sector is testament to this. More recently, Government also started applying the concept of clinical governance in healthcare, to maintain and improve the quality of patient care within the health system.

Figure 1 : A holistic approach to healthcare delivery

A holistic view of healthcare delivery inevitably includes the elderly and long-term care, as outlined in the figure above. However, this publication excludes the review of the elderly and long-term care, and instead focuses on providing an outline of Malta's key healthcare activity indicators. The first part focuses on healthcare facilities outlining recent trends in the number of hospital beds, operating theatres, human resources and their utilisation within the health sector.

Like other European countries, the challenge in Malta is to reconcile health needs, public and professional expectations with the available financial and physical resources. For this reason we then look into the financial resources, outlining inter alia, the trends in total health expenditure, its relation to other EU countries and the main financing sources.

Looking ahead Malta, like its neighbouring countries is facing a number of challenges: the demographic and epidemiological transitions associated with an ageing population, advances in medical technologies and pharmaceuticals, rising public expectations and persistent health inequalities.

Healthcare in Malta

Providers The present health service in Malta can be considered as essentially hospital-based. Specialised ambulatory services, inpatient care and highly specialised care all take place side-by-side in the main general hospital, Mater Dei, and in some other private and public hospitals, including private clinics. In terms of hospital-based care, the Government has recently embarked on the development of a new oncology centre, which should be operational by 2013.

Primary healthcare is provided by both the private sector and the state. These two systems of general practice function independently of one another. Private primary care is mostly provided by general practitioners and specialists who set up their practice within retail pharmacies. The more established practitioners and specialists typically have their own clinics. The private sector accounts for approximately two thirds of the workload in the primary healthcare2. In terms of the state primary healthcare system, the services cover general practice, which is the care offered through health centres, community care, immunisation and the school health service.

Payers

Healthcare in Malta is based on the Beveridge model3 as it is primarily funded by the tax system and operates by means of an integrated health services system that is organised at a national level. It is estimated that c. 65%4 of total health expenditure is financed through general taxation. This is complemented, to a small extent, by private financing through Out-Of-Pocket (OOP) expenditure and health insurance. The latter is a voluntary system which provides supplementary financing and does not replace any mandatory statutory contributions.

The approved estimate for recurrent expenditure within the Ministry of Health, the Elderly and Community Care (MHEC) has increased by 8% compared to 2011.5

Patients

Healthy life years is a European structural indicator that measures the life expectancy of a person based on a healthy condition without disability - it reflects the quality of life and is used as a measure of a nation's health status.

Figure 3: Healthy life years at age 65 (in 2010)

In 2010, the healthy life year indicator showed that on average, men in Malta at the age of 65 are expected to live a further 12 years in a healthy condition. Similarly, women aged 65 are expected to live a further 11.9 years. This compares favourably to the EU-27 average.

In 2010, coronary heart disease and stroke were the major cause of mortality and morbidity in Malta. This was followed by accidents for individuals under 65 years while cancers accounted for 29%6 of deaths. Other local health problems include diabetes, with a prevalence of 10%7 in adults over the age of 35 years.

Healthcare delivery: Where are we?

Healthcare indicators

Healthcare facilities

Number of hospital beds

Malta currently has a total of 1,833 hospital beds. Mater Dei is the main acute general hospital in Malta, housing a total of 825 beds. It is also the teaching hospital used by all medical, dental and pharmacy students. The new oncology centre adjacent to Mater Dei hospital is expected to accommodate a further 74 beds, of which 16 are expected to be allocated exclusively for palliative care8.

Given its geographical location, and the fact that there is equitable and freely accessible healthcare, Malta is popular amongst EU and third-party nationals. It is also susceptible to an increasing number of asylum seekers and irregular migrants. Malta's accession to the EU implies providing state healthcare to EU nationals visiting the Island and requiring state healthcare services, upon presentation of a European Health Insurance Card9. Statistics show an upward trend of non- Maltese residents10 receiving healthcare services in Malta. In 2010, c. 20,400 non-residents received healthcare in Malta, which is 13% higher than 200911.

The ratio of hospital beds available in Malta in relation to the population over the 5 year period 2005-2009 remained more or less constant at 486 beds per 100,000 inhabitants12. As at 2009, Malta was in line with countries like Greece, Netherlands and Slovenia while Germany and Austria had a higher number of hospital beds per 100,000 inhabitants. There have been various efforts, across EU member states including Malta to decrease the number of hospital beds, since a lower number of beds drives both financial and operational efficiency.

Hospital beds by ownership

Healthcare delivery in Malta is dominated by the public sector with 96% (1,748 beds) of the beds being publicly owned and managed, whilst the remaining 85 beds are privately owned. France and Italy have a similar bed ownership structure, where almost 70% of the beds are publicly owned. In contrast, only 40% of hospital beds are owned by the state in Germany. This is reflective of a country with a strong health insurance base.

Hospital beds by function

Malta allocates 58% of its beds to acute care, 28% to psychiatric care and the rest (14%) are allocated to other specialty care such as rehabilitation and oncology.

We noted that the Government is undertaking a number of initiatives to reduce the need for hospitalisation of psychiatric cases. Among these activities is the provision of care to patients in community settings.

Operating theatres

At present, there are 35 operating theatres, 25 of which are housed at Mater Dei hospital and the remaining 10 are situated in private hospitals. The number of operating theatres significantly increased in 2009 with the commissioning of Mater Dei hospital.

Public primary healthcare

At present, public primary healthcare is offered in 8 health centres and 42 clinics. These represent the hub of the primary health care services provided by the Government.

Various initiatives were undertaken by the Government to reform the primary health care sector. The Government is undertaking a â,¬1 million investment for the refurbishment of healthcare centres. Other initiatives currently underway include the redefinition of family doctors to become the first point of contact enabling the follow-up treatment of hospital - discharged patients in their nearest health centre.

Up to July 2012, public primary healthcare in Malta provided more than 678,000 services to patients including 243,000 examinations at health centres, 62,000 at clinics, 10,000 home visits, 43,000 blood tests and 14,000 X-rays. By the end of 2012, the number of services provided through the public primary health care system is projected to increase to 1.4 million services13.

Human resources

The health sector in Malta is one of the largest employers, with a total workforce of 11,10014. Malta is well placed with respect to the number of practising physicians per 100,000 population ranking midway across the EU countries15.

Over the years, Malta experienced a high outflow of qualified doctors, who pursued career specialisation in other member states. In 2008, a structured training programme was introduced offering general practitioners the possibility to take up an area of specialisation. This training programme was set up in collaboration with the UK Foundation Programme Office to encourage recently qualified Maltese doctors to continue their postgraduate specialisation locally. This process has succeeded in reducing the migration trend of newly qualified medical graduates. Complementing this programme was the material salary revisions for physicians, which came into effect in 2008. These two measures are considered the main contributors to the increase in the retention of qualified doctors from 64% in 2007 to 84% in 2010.

Other interesting trends relating to human resources are:

  • the significant increase in the take up of the nursing profession - more than 30% over the last decade16;
  • the recognition of nursing as a regulated profession;
  • an increased demand for more complex nursing care leading to the establishment of specialised degrees in a number of specific areas17;
  • the recruitment of qualified nurses and care workers from overseas to address staff shortages in the field; and
  • the increased participation of women in medical schools, surpassing the 50% mark locally.

Healthcare utilisation of resources

Average length of stay (ALOS)

The Average length of stay (ALOS) in hospitals is often regarded as an indicator of efficiency. It is generally influenced by the overall categorisation of the hospital beds, i.e. curative, psychiatric and specialty care. In broad terms, countries having a large proportion of beds allocated for long-term and convalescent patients tend to have a higher ALOS.

Based on data available, Malta registered an ALOS of 6.5 days and 6.8 days in 2009 and 2010 respectively. As at 2009, Malta was at par with Bulgaria, Ireland and Slovenia. The Nordic countries, particularly Denmark and Sweden enjoyed a low ALOS (average of 5.3 days) whilst Finland, Germany and Czech Republic had an ALOS of c. 10 days.

The ALOS for acute care in Malta stood at 4.8 days in 2009. This is one of the lowest averages in the EU and is preceded only by Finland and Sweden at 3.9 and 4.5 days respectively in 2009. Meanwhile, patients receiving acute care in Luxembourg, Germany and Belgium spent an average of 7.7 days.

In all European countries, the ALOS in hospitals has decreased, mirroring, albeit to a lesser extent, the declining trend in the number of hospital beds. This is reflective of the progress in medical technologies, which have enabled day-surgeries (i.e. less-invasive procedures), as well as programmes allowing patients to return home and receive follow-up care.

Hospital discharges

In 2009, the discharge rate in Malta was 11.5 per 100 population18. This is one of the lowest in Europe, and is in line with discharge rates of Spain and Netherlands. Discharge rates in the EU vary from 11.3 in Spain to 26.5 in Austria per 100 inhabitants.

Consultants in Malta are striving for a shorter length of stay, which will in turn increase discharge rates. The aim is to free up unnecessary occupied beds and eliminate as much as possible the time lag for alternative placement to long-term facilities or other supported community environments. This is also in line with insurance companies' policy which only cover acute care.

Number of operations

The number of operations per year in the public sector has nearly doubled over the period 1996- 2011 from 22,708 in 1996 to 43,747 in 201119. A marked increase in the number of operations was registered with the opening of Mater Dei hospital, brought about primarily by the increase in operating theatres. Another contributing factor to the increase in the number of operations is the doctors' agreement, which is essentially output-based, rather than time-based. The number of operations held between January and May of 2012 totalled 19,409 equivalent to an increase of 1,009 over the same period last year.20

Despite the marked increase in operations, the general outlook among patients is that waiting lists particularly for elective surgeries such as orthopaedic interventions and cataracts are still relatively long. Increasing the number of operations inevitably leads to a higher healthcare budget allocation, but then how sustainable is this for Malta?

Footnotes

1 World Health Organisation (WHO), (2008), Guidance on developing quality and safety strategies with a health system approach. Available from http://www.euro.who.int/data/assets/pdf_file/0011/96473/E91317.pdf . [Accessed 16 June 2012].

2 Agius A., Patient Satisfaction in Primary Healthcare, Available from https://ehealth.gov.mt/download.aspx?id=1343 [Accessed 28 May 2012].

3 In the Beveridge model, funding is based mainly on taxation and is characterized by a centrally organized National Health Service, provided mainly by public health providers. This model, developed in post-Second World War Britain, is based on universal coverage where public financing is used to fund more centralized health-care systems. This is the basis for the British National Health System, as well as the Swedish and Italian health-care systems. â€ÜHealthcare systems â€" an international review: an overview'-N. Lameire, P. Joffe and M. Wiedemann University Hospital, Gent, Belgium.

4 National Health Accounts - global health expenditure database

5 Approved estimate for MHEC in 2012 is â,¬376 million.

6 National Statistics Office Malta (2011), Demographic Review 2010.

7 Delicata C, November 2010, "Lets's take control of diabetes", Times of Malta. Available from http://www.timesofmalta.com/articles/view/20101114/ opinion/let-s-take-control-of-diabetes.336114 , [Accessed 18th June 2012].

8 Panorama inforegio (2012), Partnership in Cohesion Policy, European Commission [internet] Summer 2012 (42), p. 22 Available from http://ec.europa.eu/regional_policy/sources/docgener/panorama/pdf/mag42/mag42_en.pdf [Accessed 23 July 2012].

9 Treatment is offered on the same financial basis as local residents covered for state healthcare in the country you visit.

10 Non-Maltese residents include EU and third-party nationals.

11 National Statistics Office, Malta ( 2011), Demographic Review 2010.

12 European Health for All Database (HFA-DB). Number of hospital beds for the years 2005-2008 adjusted to exclude geriatric beds housed in St. Lukes Hospital (155 beds) and St. Vincent De Paule Residence (1,046 beds in 2005-2007, and 1,013 beds in 2008), and include growth from Karen Grech Rehabilitation Centre to Zammit Clapp (113 beds).

13 Department Of Information Malta, 2012, PR 1750. Available from http://www.doi.gov.mt/EN/press_releases/2012/08/pr1750.pdf [Accessed 9th August 2012].

14 European Foundation for the Improvement of Living and Working Conditions (Eurofound) , Employment and industrial relations in the healthcare sector, 2011. Available from http://www.eurofound.europa.eu/docs/eiro/tn1008022s/tn1008022s.pdf [Accessed : 20 June 2012].

15 European Health for All Database (HFA-DB). Data relates to 2009 and EU-27 countries exclude Cyprus, Denmark, Finland, Netherlands, Slovakia and Sweden.

16 -17 Department of Information Malta, 2012, Available from http://www.doi.gov.mt/EN/pmspchs/2011/05/04.asp [ Accessed 25 July 2012].

18 Acute care hospital discharges per 100 population - figure for Malta refers to the main acute public hospital - Mater Dei Hospital. In 2008 Cyrpus had the lowest Acute care hospital discharges per 100 at 9.2 (no data for Cyprus is available for 2009).

19 Department of Information, Malta , 2012, PR0249. Available from http://www.doi.gov.mt/EN/press_releases/2012/02/pr0249.pdf [Accessed 7 August, 2012].

20 Department of Information, Malta, 2012, PR 1661. Available from http://www.doi.gov.mt/EN/press_releases/2012/07/pr1661.pdf [Accessed 5 August, 2012].

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