This section discusses the key reforms and initiatives implemented since 2014. Reforms that were implemented between 2004 and 2013 are described in the HiT report 2014 (Azzopardi-Muscat et al., 2014). This section highlights the policy reforms pursued by the Government since its election in 2013. Whilst in some instances results have already been achieved and health system impact reported, other initiatives are still in the process of being implemented. Box6.1 lists the major reforms and policy initiatives in chronological order.
Box6.1
The House of Representatives established a Standing Committee for Health in March 2014. Previously, health matters were dealt with by the Social Affairs Committee. The original objective of the Standing Committee for Health was to facilitate consultations and discussions to encourage political consensus in health care decision-making. Between March 2014 and September 2016 the Committee met 26 times and has been highly active. Many topics have been discussed, including primary care, infection control, and mental health in adolescents. It has contributed to the formulation of important legislative acts such as the organ donation act and has presented an opportunity for civil society to engage actively with Parliament in the discussion of controversial topics, such as lowering the age of sexual consent and the availability of the morning-after pill. It has not, however, tackled the topic of health care funding sustainability specifically (Parlament ta’ Malta, 2014).
This enabling act caters for the setting-up of an advisory council composed of representatives from sectors outside health to ensure a Health in All Policies approach. The act was initially proposed as a Bill to combat obesity and was eventually widened to tackle noncommunicable diseases. It is considered to be an innovative legislative tool which provides a legal basis to issue subsidiary legislation for the prevention and care of noncommunicable diseases (Ministry for Justice, Culture and Local Government, 2016c).
This act provides for the setting-up of an organ and tissue donation register. It expressly allows a person to either opt in or opt out as a donor and to specify which organs they wish or do not wish to donate. It also provides for the regulation of procedure around live donations and updates the criminal code on organ trafficking (Ministry for Justice, Culture and Local Government, 2016c).
The National Health Systems Strategy for 2014–2020 was adopted in September 2014. The drafting of the strategy commenced in 2012 and was supported by the WHO Regional Office for Europe. The strategy informs the priorities to be developed in the health sector in the coming years in order to address the challenges facing the Maltese health system. The vision underlying the strategy is that of a “whole of society” approach to health improvement and building sustainable health systems grounded on healthy communities in line with the WHO European Health Policy – Health 2020. Strengthening prevention and primary care, making better use of technologies, harnessing existing resources and further developing health system governance are the key thrusts upon which a sustainable health system, which respects the fundamental principle of equitable access for all, is based (Health.gov.mt, 2016a).
Malta was the first country in the WHO European Region to publish a National Food and Nutrition Policy Action Plan in line with WHO recommendations (in December 2014). The Action Plan aims to tackle public health challenges facing Malta in the area of nutrition and food security. The document presents a whole of government and whole of society approach. This Policy and Action Plan complements the Healthy Weight for Life Strategy (2012), the National Cancer Plan (2011) and the Non-communicable Disease Control Strategy for Malta (2011), all of which focus on improving dietary habits in order to maximize health and well-being. In line with Health 2020, the Action Plan adopts a life-course approach since the impact of nutrition on health accumulates over time. One of the first deliverables from this Action Plan has been the implementation of the first National Food Consumption Survey (Health.gov.mt, 2016a).
A cross-party parliamentary working group was established in April 2014 to focus on diabetes (the first such group to be set up to tackle a specific disease). It was instrumental in instigating the development of the first diabetes strategy for Malta. Diabetes is common in Malta with an estimated prevalence between 6.4% (self-reported) and 10% (actual measurement). The first national diabetes strategy was published in December 2015 following an extensive period of stakeholder consultation. The overall aim of this strategy is to emphasize prevention and early diagnosis, expand treatment options, and further develop integrated care and management of diabetes so as to prevent or postpone complications. One of the main thrusts of the strategy is to make newer diabetes medicines available on the Government formulary (Health.gov.mt, 2016a) and implementation of this measure commenced in 2016.
This policy seeks to increase both the initiation of breastfeeding rates at hospital discharge and its exclusive continuation for the first six months. It aims to achieve this through the adoption of legislation and policies regulating the marketing of breast milk substitutes; encouraging a breastfeeding policy in hospitals; providing training for health professionals; and developing strategies for the promotion and support of breastfeeding in the community (Health.gov.mt, 2016a).
A draft National Alcohol Policy was published for consultation in October 2016. The National Alcohol Policy identifies general measures addressed to the entire population as well as measures targeting young people. It aims to ensure intersectoral consolidation of initiatives and coordination to prevent alcohol use among those aged under 17 and reduce the harmful use of alcohol among adults. A special focus is on measures to address drink–driving. The policy attempts to reduce and prevent the potential harm and negative consequences of alcohol on the individual, the family and society (Ministry for the Family and Social Solidarity, 2016).
From January 2017 it will be illegal to smoke tobacco in vehicles where children are present. Malta will be the sixth European country to introduce this legislation, maintaining a proactive approach to combat the harmful effects associated with tobacco smoking through passive exposure.
A Patient Charter was issued by the Parliamentary Secretary for Health for consultation between April and June 2016 (Social dialogue.gov.mt, 2016a). The Patient Charter is the first of its kind in Malta and is an important step in promoting patients’ rights. The Charter was published in November 2016 (Ministry for Health, 2016g). The obligation to issue a Patient Charter was set out in the Health Act of 2013 and is linked to the transposition obligation within EU Directive 2011/24 on patients’ rights and cross-border health care. The document is set out in eight parts: Health Protection, Access, Information, Participation and Informed Consent, Privacy and Confidentiality, Dignity and Respect, Safe Health Care, and Comments and Complaints.
The Charter proposes a particularly important undertaking, namely that, “if a predetermined maximum acceptable waiting time is not respected”, a patient would have the right to seek “healthcare through a local private healthcare provider or in another European country for state or private treatment, in accordance with the Maltese Cross-Border Healthcare Regulations, under the Health Act”. The maximum waiting period proposed is 18 months and this has attracted some criticism. In its transposition of Directive 2011/24, the Maltese Government did not include the right to seek services in the domestic private sector. The opposition party had tabled a motion calling for the legislation to be amended such that patients on waiting lists would be able to seek care at a local domestic provider, but this was not approved. The Charter now proposes that this would be possible under specific circumstances as described above. The Charter’s full implementation is expected during 2017.
Efforts to strengthen the infrastructure and provide new equipment in primary care centres have continued. The major health centres are now equipped with digital X-ray facilities allowing real-time transmission of images to the general hospital and a specialist opinion, for example in orthopaedics, to be sought, avoiding the need for patients to visit the hospital A&E department. A series of services have been introduced including: new chronic disease management clinics, plastering facilities in all health centres, and healthy lifestyle clinics. Several hospital clinics have introduced outreach services (including cardiology, gynaecology, sports and medicine, anticoagulation clinic, etc.). GPs, including private family doctors who are linked in to myHealth, have been provided with wider access for direct referral to many services which previously could only be requested by hospital specialists.
In May 2016 the first national cervical cancer screening programme was launched. Women aged 25–35 years are being invited for a smear test (Times of Malta, 2016). The colorectal cancer screening programme, offered through the faecal occult blood test, was launched for persons aged 60–64 in 2012. In 2015 the second cycle commenced and the programme was extended to persons aged up to 66 years (Times of Malta, 2015). The breast cancer screening programme has been gradually expanded and now includes women aged 50–65 years. The main challenge experienced is the need to increase invitation acceptance rates which are currently at 60% for breast cancer and 50% for colorectal cancer (Health.gov.mt, 2016b).
The National Health Systems Strategy adopted in 2014 highlights the importance of further developing the use of ICT in the Maltese health system. The myHealth system, which is a system that allows patients to access their electronic record through a nominated doctor of their choice, has been improved since its rollout in 2012 and its coverage multiplied through an outreach working around the restrictions of the e-ID system. An investment plan for eHealth infrastructure, which envisages the creation of electronic patient records in primary health care, e-prescription services on a national basis, patient registries, and the necessary enablers for e-prescriptions (including the Government Formulary for medicine, the entitlements approval system, and health data exchange backbone), has been drawn up. This will lead to the development of national electronic health records which ‘pull’ data from all electronic patient data.
In 2015 the acute general hospital, MDH, launched a campaign called Care and Cure. This campaign was intended to render the hospitalization experience a more positive one, as well as to disseminate information for patients and visitors. Visiting hours were increased and information about aspects of care such as infection prevention was made available (Mater Dei Hospital, 2015). In addition, a Patient Safety Committee (PaSQIT) was established to investigate incidents and promote patient safety. Since its inception the committee has conducted over 150 cases of root cause analysis.
Limited bed capacity has been one of the major supply constraints impeding better health system performance. Bed capacity in MDH has been increased by 68 beds through the creation of two additional wards and the number of substandard beds has declined. Nevertheless, this was deemed insufficient and plans are being developed to build a new maternity wing on the MDH site, thereby increasing capacity by around 300 beds. The target set is that substandard beds (e.g. trolleys, holding bays) will cease to exist (Mater Dei Hospital, Personal Communication, 2016).
A series of measures have been introduced to reduce waiting lists for certain diagnostic and surgical procedures. This has been acknowledged in the Commission’s assessment report on the National Reform Programme (European Commission, 2016b). Such measures have improved access in key areas. For example, waiting time for MRI investigations has decreased from around 18 months to around four months. This has been possible due to a second MRI machine in the public sector and the extension of appointments to twilight hours (use of equipment on a 24/7 basis), as well as outsourcing procedures to the private sector. Such schemes have been designed to incentivize health professionals to deliver more within the public health care system to avoid the creation of perverse incentives. For echocardiograms, a 30-month average waiting time has gone down to two months. The average waiting time for an ultrasound is around five months and that for a CT scan around six months. Waiting time for cataract surgery has been reduced from three years to six months. Waiting times for hip and knee replacements are also being reduced gradually.
These results have been achieved through a combination of increasing the number of procedures performed in the public hospitals through, for example, the introduction of routine Sunday lists, as well as outsourcing procedures to the private sector. In addition, a waiting list management system ensures that patients who are no longer deemed to require the intervention or who need to lose weight prior to being eligible for the intervention do not feature on the waiting lists (Mater Dei Hospital, Personal Communication, 2016).
A series of reforms were implemented and the layout of the A&E department was completely redesigned, providing more cubicles for patients to be seen. In addition, the service of a reception nurse was introduced. This ensures that patients who would be better served by being seen directly in a specialty department (depending on the type of complaint they have) would be immediately diverted to a particular department. A patient tracking system was developed and a new minor care clinic was established.
Improvements in bed management mean that patients who need to be admitted to hospital no longer have to wait for a long time in A&E until a bed is found.
In December 2015 a purposely designed separate emergency department for children was inaugurated. In 2016, 75% of discharged patients had a total length of stay in A&E of less than four hours, whilst 80% of admitted patients had a total length of stay in A&E of less than six hours (Mater Dei Hospital, Personal Communication, 2016).
The service was established in 2014, having started with a project funded through the European Social Fund aimed at linking hospital services with community services following patient discharge. Nurses received training in Northern Ireland. The discharge planning process starts upon admission for patients who are deemed to require post-discharge support. This project contributed both to a decrease in the length of stay and to a decrease in hospital readmission rates (Directorate for Nursing Services, Personal Communication, 2016).
Towards the end of 2014 this new oncology hospital, based on the same grounds as the acute hospital MDH, received its first patients. The centre, named after the first President of the Republic of Malta, was funded through the European Regional Development Fund (ERDF 2007–2013) and replaced the former hospital where cancer patients previously received treatment. Paediatric oncology and haematology services, previously housed within MDH, were incorporated into the SAMOC, thereby releasing much-needed beds for acute care services. Investment in new radiotherapy equipment enables the delivery of precision radiotherapy in stronger doses, thereby reducing the number of sessions required, as well as the duration of each session. Tumours previously treated abroad can now be treated locally. The project was also the catalyst for the establishment of university training programmes leading to qualifications in therapeutic radiography and medical physics (Times of Malta, 2014; Health.gov.mt, 2016c).
The Government has entered into a 30-year contract with Vitals Global Healthcare, a private contractor for the refurbishment, development and management of three hospitals in Malta and Gozo. The private contractor will be responsible for capital investment. The new Gozo hospital and the development of Karin Grech and St Luke’s are expected to be completed within 24 months from the start of construction, but the latter date cannot be established as the necessary building permits are still pending. The Government is anticipating paying the sum of €55 million annually into the partnership, which is the sum currently paid for the running of these hospitals (Allied Newspapers Ltd, 2016). All Government workers in the three hospitals will remain Government employees, but the management of the hospitals and staff was handed over to the private contractor in June 2016. Agreements between the Government and unions on the future of their employees have been achieved with the Malta Union of Nurses and Midwives and the General Workers Union, but remains outstanding with the Medical Association of Malta and the UHM Voice of the Workers. Redacted versions of the privatization contracts were made public in October 2016. The Medical Association of Malta and the UHM Voice of the Workers have called for an investigation by the Public Accounts Committee. The extent to which this initiative will alter the landscape of the Maltese health system will depend on the way it is going to be implemented. Concerns have been raised about threats to equity of the health system, long considered one of the strong hallmarks of the Maltese health system. Yet from public statements, the Government has sought to provide reassurance that no changes in terms of access and coverage will occur. This is a particularly important point for the Gozo hospital, where the only hospital on the island has been handed over through this 30-year concession. On a positive note, it is hoped that standards of care will improve through the pursuit of projects such as international hospital accreditation. However, on a more cautious note, critics fear that the hospitals will eventually need a larger Government subvention and therefore it is not possible to establish at this stage whether this reform will contribute to enhanced health system sustainability or will in itself trigger higher levels of expenditure. The impact of this reform will require close monitoring over the next three to five years.
The Gozo hospital will be modernized, expanded and upgraded as part of the public–private partnership agreement. This will not only improve access for Gozitans and expand the health care capacity available for residents in Malta but is also expected to create niche medical tourism. The first new service launched by the privately owned hospital is a helicopter air ambulance service for the transfer of seriously ill patients needing emergency treatment in Malta. This replaces the need to rely on the helicopter service provided by the Armed Forces of Malta and reduces transit time whilst improving facilities available during air transfer (The Malta Independent, 2016a). Its increased capacity should also enable the Barts and the London School of Medicine and Dentistry to establish an overseas medical school at Gozo General Hospital. This is expected to host the first students in September 2017 and will build to a capacity of 300 medical students by 2022.
Through the same agreement, the private sector will be investing in the development of a rehabilitation hospital on the grounds of the former St Luke’s Hospital, which was left mostly unutilized following the migration of services to MDH. This facility is intended to introduce services that are presently not available in Malta. While it is primarily geared towards medical tourism, 80 beds will be exclusively designated for use by domestic patients through the public health services. The hospital will have 350 beds and is expected to be completed in mid-2018 (The Malta Independent, 2016b).
The Karin Grech Hospital, which is currently used both for geriatric rehabilitation and nursing care, will be taken over through the public–private partnership and used as a 250-bed geriatric hospital with 125 beds available for the public sector and 125 beds for the private sector.
The procurement of medicines and medical supplies was identified as a key outstanding challenge in the 2014 HiT report (Azzopardi-Muscat et al., 2014). Stock-outs for common medicines in the public health system were a frequent occurrence due to bureaucratic processes and procedures, lack of forecasting and inadequate budgetary provision. In 2015 the European Commission noted that “an improvement in procurement and distribution processes for medicines and medical devices led to substantial savings. Furthermore, a pay per use system on high costs devices has reduced the holding of stock” (European Commission, 2015b). The problem with out-of-stock medicines has therefore been successfully tackled. The POYC scheme has continued to be strengthened with the next phase being a pilot project to deliver medicines directly to the private residences of elderly people in line with the Government’s electoral programme. E-prescription services are also being introduced.
Access to innovative medicines remains a considerable challenge. The GFLAC has introduced the concept of clinical pathways and protocols for the evaluation of new medicines. This means that evaluation of new medicines now takes place around the concept of diseases management moving away from the introduction of single medicines. Some inroads have been made with the use of bio-similars, and this also leads to savings in the medicines budget. Savings can then be used to procure expensive new medicines. The Government is embarking on the use of Managed Entry Agreements. Furthermore, in recent years the Malta Community Chest Fund (a philanthropic foundation presided over by the President of Malta) has extended its role in the financing of new medicines, particularly those for cancer that are not yet included on the Government Formulary. Cancer medicines now account for the largest expenditure of this Fund (Malta Community Chest Fund Foundation, 2016). In spite of these measures, funding innovative medicines remains an important challenge to the reconciliation of the dual objectives of health system access and sustainability.