Malta is shaking up its healthcare sector and has invited the private sector to play a greater role. Long wait-lists for non-emergency surgeries and a shortage of hospital beds, coupled with a commitment to provide free health services, have prompted the Maltese government to make healthcare reform a priority. The vision is to transform the healthcare sector into a medical education and health tourism hub, while adding much needed extra capacity for local patients seeking high-quality medical care and health facilities. The state will remain a major shareholder in healthcare provision on the island, however specialised services in areas such as oncology, aged care, rehabilitation and the treatment of trauma will also be provided by the private sector. As part of this reform initiative, Malta has been seeking to establish partnerships with international healthcare providers and medical schools.
A Health Vocation
Malta has a medical tradition that can be traced back to the Knights of St John when the country’s hospital gained fame across Europe for the quality of its care. During the First World War the island affectionately earned the name ‘Nurse of the Mediterranean’ when allied soldiers were evacuated to Malta for treatment and rehabilitation. At its peek, Malta had 25,000 beds filled with service men being treated at the island’s 27 hospitals, a role that was repeated in 2011 when evacuees from Libya received treatment in Malta. Naturally, the island’s health sector primarily serves the local population.
State-funded healthcare is available free to all citizens and long-term residents. Over the past few years, the level of public expenditure in the sector has amounted to around 6.5% of GDP, which is on a par with the EU member states’ average. Nevertheless, private healthcare has long been coexisting with the state system in the form of private doctors, clinics and even hospitals. However, it was only recently that Malta decided to encourage greater private sector participation and to build on the island’s century old role as a medical centre in the Mediterranean, which can cater both for local and international demands.
"Malta offers high quality care and we are encouraging further investment into this sector to meet the needs of our own ageing population and the increasing number of expat retirees who are choosing to live here. We believe the sector could be an important contributor to the Maltese economy. The aged care industry provides a lot of opportunity for companies to deliver new care homes, develop new products, services and applications."
Anthony Agius Decelis, Parliamentary Secretary for Persons with Disability and Active Ageing
The government has overall responsibility for the healthcare system, exercised through the Ministry of Health. The Ministry, like many of its European counterparts, has been facing the challenge of finding ways to keep health costs in check. With increasing demands, an ageing population and rising expectations, Malta has sought to find innovative ways to bolster the capacity of the health service and future-proof the country’s needs; while at the same time internationalising the sector to tap into the ever-growing market of patients seeking treatment outside their home countries. To deliver its vision of providing the best high-quality healthcare system in Europe, the island’s political leaders recognised that Malta would need to seek private sector investment to construct and modernise its hospitals and to totally overhaul the country’s healthcare offerings. They have attracted a number of private sector players as part of this drive.
At a Crossroads
The largest private player entering Malta’s healthcare arena was Vitals Global Healthcare (VGH). In 2016, the Group was granted a 30-year concession to upgrade and operate three hospitals: one in Gozo and two in Malta. The company had to invest €220 million over the following two years to transform the hospitals into state-of-the-art facilities to attract medical tourism. As part of the public- private partnership, the government bound itself to buy a number of beds to be used as part of the public healthcare system. VGH’s target was that it would attract at least 5,000 medical tourists a year. However, the project has attracted controversy and opposition from Malta’s doctor’s union and other stakeholders due to a lack of government transparency when awarding the contract to VGH as well as funding issues. In February 2018, US healthcare giant Steward Heath Care finalised an agreement to take over the concession and continue the work that began under Vitals.
VGH’s brief also included building a new medical school capable of hosting 300 students in Gozo, in addition to a nursing training college. The medical school, which welcomed its first students in September 2017, is run by Barts and The London School of Medicine and Dentistry. During its first year of operations, while works on its permanent campus are completed, the medical school is housed at a school in Gozo. Malta’s new vocation as a medical teaching hub has also attracted the Royal College of Surgeons of Ireland, which recently made Malta a centre for examinations for surgeons.
"One of our priorities is to cut the waiting list for residential homes for the elderly. While Government is operating a number of care homes, the elderly care sector has recently seen the entrance of new private investors, and we are looking at further strengthening our cooperation with the private sector to provide long-term bed space."
Michael Falzon, Minister for the Family, Children’s Rights and Social Solidarity
Malta’s primary hospital Mater Dei, which has 25 operating theatres and some 900 beds, continues to be operated by the Maltese government. It also runs the new 113-bed Sir Anthony Mamo Oncology centre adjacent to Mater Dei Hospital, which was inaugurated in 2015 and saw the migration of services from Boffa Hospital in Floriana.
Acknowledging the fact that some specialist services cannot be provided due to the country’s small size, the government sponsors trips for treatment abroad. In addition, the government runs some 40 clinics and nine health centres offering the full range of preventive, curative and rehabilitative services. Primary care is also available from private general practitioners (GPs).
Several private clinics and hospitals, the most renowned being the St James Hospital Group, complement Malta’s healthcare infrastructure. The Group owns and runs an 80-bed hospital in Sliema, a 6-bed clinic in Zabbar, and an outpatient clinic in Burmarrad and Zebbug, as well as a new eye clinic in Birkirkara. The Group also operates one hospital in Libya and another in Hungary. In addition, a privately run boutique hospital with 40 beds, the St Thomas Hospital, was opened in Qormi in 2016 with the intention to attract medical tourists. However, the hospital has signed an agreement with the government to perform around 200 operations per year for the national health service to reduce the waiting list. In 2015, plans had been announced for a new healthcare centre at Smart City, which was reportedly backed by investment from renowned company Johnson & Johnson. However, the project has yet to take off.
Better Health Services
Waiting times in Malta’s main public hospital have already been reduced as a result of higher number of specialists in attendance as well as the government’s decision to buy services from the private sector. Maltese health outcomes have also seen improvement as a result of better quality care.
Life expectancy climbed to 82 years in Malta in 2015, placing Malta among the top 20 highest life expectancy countries in the world. The country has also been seeking to keep pace with the latest healthcare developments. For example, the new oncology centre has made possible newer diagnostic and treatment modalities for cancer patients. Healthcare services have also been extended, and a number of preventive treatment programmes have been introduced, including free breast-cancer and cervical cancer screening. The government will now shift its focus on the provision of more modern drugs for the treatment of cancer. Despite all the positive developments and a concerted effort to create sustainable healthcare, the sector still faces some challenges. The lack of a strong primary care system is widely seen as a key reason for capacity constraints at Malta’s main hospital, as it has made the hospital the first port of call for the Maltese, even when suffering only minor discomforts. More and better-equipped primary healthcare centres, including a regional clinic in Paola that can cater for 25,000 people, are now being introduced to strengthen the gatekeeper function of family doctors. Lifestyle screening, and in particular tackling issues such as childhood obesity, is also high on government’s health agenda. Additionally, the government is trialling a model that sees family doctors providing follow-up care for a number of chronic conditions, such as breast cancer and mental health issues.
"One of the problems for any health minister is, of course, sustainability. Our health system is free, and we want to keep of standard of excellence. We are determined to keep it both free and excellent. The investment we are seeing in our health system consolidates this aim and further establishes Malta’s credentials as a centre for medical tourism. An exciting development is that Malta will be the first country worldwide to introduce wide ranging remote patient monitoring, which in our trials reduced hospital admissions by 40%."
Chris Faerne, Minister for Health & Deputy Prime Minister
Forging New Partnerships
Malta is seeking further private capital to supplement the public sector investment. Industry associations forecast that by 2050 the island will need no fewer than 18,000 more beds for the elderly. Such a figure indicates that there is ample scope for more private healthcare providers to enter the market.
The country is inviting international and local stakeholders from the public and private sectors to discuss future healthcare solutions in the area of eHealth, medical technologies and other tools that can support healthcare workers. The island is also positioning itself as a production centre for medicinal marijuana, and a number of companies have already expressed their interest after legislation providing for the production of cannabis for medical use had been published.
"For medical tourism to really take off in Malta, we need not only several well-equipped hospitals, but also a greater level of specialisation that would attract foreign patients from abroad. At this stage, we can only achieve this by attracting specialist doctors, and we need incentives to encourage them to come to Malta."
Dr Josie Muscat, Chairman of the St James Hospital Group
Attracting Foreign Specialists
The drive to attract foreign doctors and nurses will continue for the foreseeable future as it will be key to the island’s success to establish itself as a health tourism destination. Many medical practitioners have trained in the UK and the US. Traditionally, Malta has experienced a high outflow of qualified doctors, with many newly graduated doctors deciding to continue their studies abroad, but in an effort to attract and retain highly qualified medical professionals, the country has signed cooperation agreements with institutes abroad, allowing young doctors to specialise in Malta. This process has helped to reduce the exodus of medical graduates. As an English-speaking nation, Malta is also increasingly attracting foreign doctors, and Malta’s health ministry is keen to facilitate matters in particular for non-EEA medical professionals to work and live in Malta.
Malta’s vision for the future includes a fast and efficient healthcare sector, including better amenities and quality of service for the Maltese population while developing Malta and Gozo into a reputable health-tourism hub. The intention is to place the country firmly on the map for not only cosmetic interventions but also for specialist services. While Malta’s healthcare sector is currently going through turbulent times and the road to achieving this goal has not been smooth, the ultimate objective is credible, and there is a business case for it. The island’s decision to choose the model of mixing public and private care goes a long way toward Malta’s ability to subsidise the sector and provide healthcare services free of charge for its people. In its efforts to bring health tourists to Malta, the island can tap into a strong regional market, including patients wanting to escape long wait-list in other EU countries. There is widespread agreement that medical tourism will increase in importance worldwide in the coming years. One study estimates that the global medical tourism market will reach US$32.5 billion by the end of 2019. This bodes well for Malta’s ambition of becoming a centre of medical excellence that attracts the greatest and latest medical expertise and technology to the island.