The Healthcare Framework in Malta

Overview

Innovative and promising therapies do not always reach the patient, so patients in the EU still have different levels of access to medicines. Companies are not obliged to market a medicine in all EU countries; they may decide not to market their medicines in, or withdraw them from, one or more countries. This can be due to various factors, such as national pricing and reimbursement policies, size of the population, the organisation of health systems and national administrative procedures resulting in smaller and less wealthy markets in particular facing these problems – The European Commssion, EU Pharmaceutical Strategy. 

Malta is the European Union’s (EU) smallest Member State and has implemented all EU legislation. Malta’s population, comprising less than half a million people, enjoys generally good health and one of the longest life expectancies in the EU. However, high obesity rates among adults and adolescents pose a serious threat to public health. The National Health Service provides universal coverage for a comprehensive benefit package, while the private sector plays a key role in the delivery of primary care.

Malta recorded one of the largest increases in per capita health expenditure in the EU during the past 10 years. Health spending per person in 2017 was €2,732, more than 60 per cent higher than in 2007, although it remains below the EU average. This equates to 9.3 per cent of the GDP, also below the EU average of 9.8 per cent. Although the health system provides practically universal coverage, out-of-pocket spending in 2017 was the joint fourth highest in the EU (34.6 per cent compared to an average of 15.8 per cent), due to high private spending on outpatient services, primary care, and pharmaceuticals. 

The healthcare economy

i The Maltese healthcare market

Malta has a two-tier or split healthcare service market, with two separate and distinct regimes that operate in parallel.

The National Health Service

The public healthcare system is funded by the state. Patients’ entitlement to medication on the public health market (national health services) outside a Maltese government hospital setting is assessed on the basis of disease or means by virtue of the Social Security Act (Chapter 318 of the Laws of Malta).

National health services are funded by taxpayers and managed by the Maltese government (the Ministry for Health). Medicinal products listed in the government formulary are provided free of charge to eligible patients (end user).

Malta has transposed and implemented the EU transparency laws that apply to medicinal products procured via national health services (i.e., the national formulary). The applicable Maltese law is the Availability of Medicinal Products within the Government Health Services Regulations (SL 458.31).

Outpatient medical care coverage is below 60 per cent in Malta. On average across EU countries, around one‐fifth of all health spending is paid out-of-pocket by households, but this proportion exceeds more than one‐third in Malta and some other EU countries. 

The private market

The private market services the healthcare sector that is not covered and supported by the Malta National Health Service and operates independently of the Malta National Health Service. Medicinal products for human use purchased on the private market (i.e., from a pharmacy at retail level, sold to the pharmacy by the wholesale dealer or administered by a private hospital on an in-patient basis) are an out-of-pocket cost to the patient or consumer and, in the case of prescription medicines, are prescribed by a doctor.

ii The role of health insurance

Taxes fund Malta’s public healthcare system. Malta provides healthcare services, which are free at the point of delivery to all Maltese citizens and European Union residents with a European Health Insurance Card (EHIC), although the EHIC is not considered an adequate substitute for comprehensive health coverage. The Maltese Health Ministry advises foreign residents to take out private medical insurance.

In order to be eligible to file an application to acquire Maltese citizenship by naturalisation for exceptional services by direct investment, the criteria established by the Granting of Citizenship for Exceptional Services Regulations (SL 188.06) must be satisfied. 

iii Funding and payment for specific services

Malta’s health system is a tax-financed national health service that provides practically universal coverage to all residents covered by social security legislation or humanitarian exemption. Most healthcare services are provided free at the point of use. Medicinal products prescribed by physicians during inpatient care in public hospitals and generally three days post-discharge are available free of charge at point of delivery to entitled persons and for outpatient treatment for certain chronic conditions. Other medicines and medical devices must be paid for out of pocket. Per capita spending on pharmaceuticals and medical devices is high, constituting 21 per cent of total spending, and is higher than the EU average. Projected government spending increases due to population ageing pose some fiscal sustainability risks in the long term.

Primary/family medicine, hospitals, and social care

i Delivery of healthcare services

Public health governance, regulation, and financing are centralised under, and managed by, the Ministry for Health. The Ministry is also the main provider of public healthcare services, with the private sector complementing provision, especially for primary care and outpatient services.

Strengthening primary care to improve efficiency and better serve those living with chronic conditions is an important policy goal. Projected spending increases due to population ageing pose some fiscal sustainability risks in the long term. Reorienting service delivery away from hospitals towards primary care to improve efficiency and reduce public spending remains a key priority for Malta.

ii The role of the private sector

Inpatient care is provided mainly by Malta’s only ‘regional’ public hospital, Mater Dei, with primary and outpatient care delivered by both public and private providers. Long-term care for older people is delivered by the public and private sectors as well as by religious (Roman Catholic) organisations. The private sector plays an important role in the delivery of primary care despite the existence of a state-run primary care system. Private General Practitioners (GPs) account for 70 per cent of primary care visits.

For the past 25 years the largest private hospital in Malta has been the St James Hospital Group based in four different locations in Malta, offering in-patient and out-patient services, the immediate medical care unit (IMCU), a pharmacy, surgical interventions, and physiotherapy. Other private hospitals and clinics also operate in Malta.

iii Access to medical consultants

Hospital consultants see patients following a referral from a GP (both from the private and public sectors) or other doctor. Many patients opt to pay out of pocket to see private specialists without a referral to avoid long waiting lists in the public sector. This creates a ‘two-tier’ system, with private-sector GPs and specialists working in both the public and private sectors being able to refer patients back to public-sector services.

iv Data protection laws

The EU member states’ data protection law has been significantly strengthened by the EU General Data Protection Regulation (GDPR). The GDPR came into effect on 25 May 2018 and has direct effect and therefore did not require transposition into Maltese law.

v Universal electronic medical records

Data processing in the myHealth website is in compliance with the provisions of the Data Protection Act (Chapter 440 of the Laws of Malta). The website allows Maltese citizens and their doctors to view medical records. Patients with a Maltese electronic identity card, or e-ID, can log in to view case summaries, upcoming appointments, Pharmacy of Your Choice entitlement, and when released: laboratory results, and medical imaging reports. Doctors linked to the patient through the myHealth website can see patients’ results and reports as soon as they are published.

Gnomon Informatics, a Thessaloniki-based SME, announced in 2019 the rolling out of interoperable e-health management solutions across Europe. The openDECIPHER solution, which it developed during the EU-funded DECIPHER pre-commercial procurement, paved the way for the company to win e-health deployment contracts in Cyprus, Ireland, Malta, Luxembourg, Greece, Belgium and Switzerland. In 2021, Gnomon Informatics SA announced the extension of the collaboration with the Ministry for Health of Malta for the support and the upgrade of the cross-border e-health services of the country. This was developed in the context of the pan-European initiative, coordinated by the eHDSI (eHealth Digital Service Infrastructure), which aims to interconnect the e-health national systems of the EU countries. Specifically, it enables EU Member States to provide cross-border healthcare services to EU citizens by allowing the cross-border exchange of clinical documents (Patient Summary and e-Prescription). Malta uses the eHealthPassTM platform of Gnomon Informatics SA to interconnect the national healthcare infrastructure with the National Contact Point (NCP) for cross-border health using international and open interoperability standards. The system is operational and allows the Maltese citizens who travel within EU and the EU citizens who travel to Malta to access cross-border healthcare. 

Published by Lexology on 7 September 2022 as an extract from the Malta chapter of The Healthcare Law Review 8th edition authored by Dr Anthia A Zammit