First published in ITIJ 129, October 2011
How do you make a Maltese cross? Threaten to cut back on a free, public healthcare system that might be the envy of many larger developed nations. Robin Gauldie reports
With a long historic association with one of the world’s best-known voluntary healthcare brands, it’s not surprising that Malta should have a reputation for healthcare that citizens of many much larger developed nations might envy. The World Health Organisation ranks Malta’s health system as the fifth best in the world – well ahead of the UK, the US, Canada or Australia.
Malta’s association with one of the caring profession’s most cherished icons – the angular Cross of St John, better known as the ‘Maltese Cross’ – goes all the way back to the 16th Century. The Knights Hospitallers of the Order of St John originated during the medieval Crusades, as a monastic order ministering to the sick and wounded. Over several centuries, they became less caring and more militant. Exiled from the Holy Land, they held the Greek island of Rhodes until they were turfed out by the Ottoman Sultan Suleiman the Magnificent in 1521 – after which Suleiman’s Christian arch-enemy, the Holy Roman Emperor Charles V, granted them Malta and its little neighbours, Gozo and Comino.
The Knights withstood yet another great Turkish siege in 1565, and hung onto Malta until it became part of the British Empire (after a brief French occupation). The island nation became independent in 1964, and joined the European Union in 2004.
With a land area of a little more than 300 square kilometres and a population of less than 420,000, this little Mediterranean nation is one of the most densely populated in the world. Almost all of its people live on Malta, the main island, with around 31,000 on Gozo (which is adequately provided for by its own modern, 159-bed Gozo General Hospital) and only a handful of inhabitants on much smaller Comino, which is designated as a nature reserve.
The World Health Organisation ranks Malta’s health system as the fifth best in the world
Poised between Europe, North Africa and the Middle East, Malta has been a crossroads of multiple civilisations since prehistoric times – as evidenced by the nine UNESCO World Heritage Sites, ranging from ancient megalithic temples to remarkable medieval fortifications, which attract more than one million visitors to Malta and its two tinier neighbours every year.
Overall, tourism is estimated to contribute between 25 per cent to 40 per cent of the nation’s economy. Visitor numbers in recent years have hovered around 1.2 million annually, dipped in 2008-2009, but recovered to more than 1.3 million in 2010, with further increases in 2011. Almost 87 per cent of visitors originate from the European Union (EU), with the UK providing the lion’s share (415,120 visitors in 2010). Tourism expenditure in 2010 was €1.1 billion.
Tourism industry confidence in the island’s tourism brand remains strong, with airlines including Thomas Cook, Ryanair, Bmibaby and EasyJet significantly expanding their airlift from the UK in 2010-2011, and other carriers from European Union nations – notably Spain and Scandinavia – also expanding capacity.
Malta International Airport, at Luqa, is the country’s only air gateway, while the smaller, neighbouring island of Gozo has a heliport, which has been unused for scheduled services since 2006, but which could be used for emergency helicopter medevac purposes. Gozo is also linked to Valletta’s Grand Harbour by scheduled floatplane services, operated by Harbour Air Malta.
A glance at the map quickly pinpoints Malta’s outstanding strategic location. Tripoli, the Libyan capital, lies only 355 km to the south. The Tunisian coast is even closer, just 288km to the southwest. Sicily is less than 100 km away, while Alexandria in Egypt is 1,510 km to the east.
The island’s proximity to Libya has offered both opportunity and challenge, and never more so than at present. Several major oil and construction companies use Malta as an offshore logistical base for their Libyan operations, and it has a significant role in providing emergency medical evacuation from Libya during the recent unrest. The World Health Organisation’s announcement in August that it would use Malta as a base to ferry aid to Libya underlines that role.
Fascinating as its ancient and medieval heritage is, Malta’s mellow climate is its most powerful tourism magnet. The capital, Valletta, claims to have the warmest winters of any European capital city, with a daily average of five hours of sunshine in December and temperatures which can reach daytime highs of 20°C even during January, the coldest month of the year. In August, the hottest month, daytime temperatures range from 28°C to 34°C. That climate – plus a long connection with Britain – makes Malta a year-round favourite with holidaymakers from the UK, which generates around 450,000 visitors to Malta annually.
Traditionally, that mellow climate, plus a relatively low cost of living, a low crime rate and the cosy familiarity of a country where almost everyone speaks English and which is only three hours flying time from the former colonial power, has also attracted a substantial number of older British retired expatriates and long-stay winter visitors.
Unlike many Mediterranean island destinations, ‘adrenaline’ activities, extreme sports, and frenetic nightlife – all of which generate a steady flow of insurance claims in destinations such as Greece and Spain – make up only a small part of Malta’s tourism portfolio.
The destination also appeals to a relatively more mature (and hence, perhaps, more risk-averse) market sector. Of the total, more than 914,000 visitors each year are over 25, and 457,760 are in the 45-64 age bracket.
Road accident fatalities are low (around five per 100,000 head of population), as is violent crime against tourists, according to the UK Foreign and Commonwealth Office.
Several major oil and construction companies use Malta as an offshore logistical base for their Libyan operations, and it has a significant role in providing emergency medical evacuation from Libya during the recent unrest
Malta’s most popular potentially hazardous holiday sport is scuba diving. Its clear seas, plentiful marine life and an undersea chart dotted with World War II-era wrecks make it a popular destination from divers from all over Europe, and there are a number of professionally-run dive centres on Malta and Gozo. There is adequate provision for diving-related medical emergencies, with four hyperbaric chambers, including one each in Mater Dei and in Gozo General Hospital, and two further chambers in private clinics.
Since 2010, the Maltese Tourism Authority (MTA) has actively marketed Malta as a medical tourism destination, with the UK as its main target market. Within both the public and private sectors, English is fluently spoken by all personnel, and many are also fluent in Italian, German and Arabic, as well as in Malta’s own idiosyncratic mother tongue, which blends Italian, Arabic and other influences.
Other medical tourism markets identified by the MTA – North Africa, the Middle East, Russia and North America – look less promising for a variety of reasons, from political turmoil in North Africa and the Middle East to the relatively poor air access from the US and Canada.
That said, Malta could benefit as a medical tourism destination for clients from Europe and the Middle East as a result of the recent upheaval in Tunisia, a geographically comparable destination whose ambitions to assert itself as a medical tourism destination must for now be on hold until its political stability is assured. However, although Malta’s health service is highly regarded internationally, none of its hospitals has yet received independent international accreditation.
The state currently provides a comprehensive health service free at point of use for all residents. However, public health provision has recently become a hot political issue. The ruling National Party makes no bones about its commitment to privatising a wide range of Malta’s public sector, and the opposition Labour Party has alleged that the government has plans to make cuts to free healthcare – claims that were strengthened by comments from Joseph Caruana, the recently-appointed chief executive officer of Mater Dei Hospital, the country’s largest and most modern public hospital.
Mater Dei, which opened in 2007 (at a cost estimated at around €500 million), is one of Europe’s largest hospitals. With more than 900 beds and 25 operating theatres, it has the potential to help Malta become a major player in the medical tourism field.
But, in an interview with Malta’s Sunday Times newspaper, Caruana was quoted as saying that free healthcare in Malta was ‘definitely not sustainable’. It is a token of how strongly Maltese voters cherish their state healthcare system that the prime minister, Lawrence Gonzi, promptly went on record to reaffirm the government’s commitment to a free public health system. The government, he said, ‘did not view the provision of medical services as a business’.
Could the provision of emergency and elective medical treatment become bigger business for Malta in the near future? A recent development that will be welcomed by travel insurers is the opening by the St James Hospital group of a new Immediate Medical Care Unit (IMCU), the St James Zebbug Highway Clinic. Offering emergency first aid, medical assessment and treatment on a no-appointment basis, the clinic promises facilities such as ECG and blood investigation with results ‘within minutes’. This is the latest addition to the St James group’s portfolio of hospitals and clinics, which includes its flagship St James Capua Hospital in Sliema, with 80 beds and five operating theatres; the small St James Zabbar, with six beds and two theatres; and hospitals in Tripoli and Hungary.
The St James group is actively seeking to attract international medical tourists and applied for international healthcare accreditation in 2008 through the UK-based Trent Accreditation Scheme, but the closure of TAS last year has delayed its plans for fully accredited status.
The state currently provides a comprehensive health service free at point of use for all residents
Meanwhile, a question mark still hangs over the future of one of the country’s two main private hospitals, the 75-bed St Philip’s in Santa Venera, which closed in 2010 and is currently for sale, with rumours that it may be acquired by the government. However, the hospital is owned by a National Party politician, Dr Frank Portelli, which makes its possible acquisition by the public sector somewhat politically sensitive.
The government has also been criticised by Malta’s healthcare professionals for what they claim is a failure to provide enough nurses to meet the needs of patients. The Maltese Union of Midwives and Nurses has called the current Ministry of Health ‘totally inefficient’, and last year warned that the public health service faced a shortfall of 700 nursing staff, leading to patients in emergency departments waiting up to six hours for beds. Health service unions took industrial action in protest against staff shortages in 2010. The government promised to remedy the situation by recruiting more nursing staff from Malta and abroad, but staff shortages continue to be an issue.
Malta’s miniature size means transferring emergency cases to its major hospitals poses few logistical challenges. An investment of some €55 million from European Union regional funds has improved the country’s main roads over the last decade, but there is a need for further improvement of the road network. Ambulance services are provided by Mater Dei’s accident and emergency department, by the voluntary St John Ambulance organisation and by a new private operator, FAS, with a fleet of ten vehicles working closely with Mater Dei and with the island’s private hospitals.
Malta’s geographical position gives it considerable potential as a base for aeromedical evacuation services. Over several decades, it has become a useful hub for medevac operations both in and out of nearby North Africa. Whether the current instability in the region poses a threat or offers opportunity for Malta, however, remains to be seen.
The air wing of the Armed Forces of Malta (AFM) in theory has a remit for search and rescue services over a wide swathe of the southern Mediterranean, from Libya and Tunisian waters as far east as the Greek island of Crete. However, the air wing’s undeniably elderly fleet, which comprises three SA316B Alouette III helicopters, one Nardi-Hughes 369 HM, and fixed-wing aircraft including four Scottish Aviation Bulldogs and two Islanders, currently has no dedicated medevac aircraft.
"A recent development that will be welcomed by travel insurers is the opening by the St James Hospital group of a new Immediate Medical Care Unit"
Private air ambulance service is provided by Medilink International Air Ambulance (MIAA), which has taken advantage of Malta’s handy location to establish itself as a provider of short, medium and long-haul medevac flights. Medilink has built up close relationships with oil companies operating in Libya, with a base in Tripoli. In June 2010, it launched a dedicated Malta-based air ambulance service with a Learjet 36A (in conjunction with Florida-based Jet ICU) and a King Air 200 (operated by UK company Synergy Aviation), both operating from Malta International Airport at Luqa.
On the run
In the 1970s, Malta’s government forged links with the Libyan regime, which financed an array of public-sector works. In 2011, those links were swiftly repudiated, with the local council in Paola voting to wipe the name of the former Libyan despot from its long-standing Gaddafi Gardens, originally named in his honour. It was even suggested, as the Gaddafi regime collapsed, that its leaders might attempt to use Malta as a staging post as they fled Tripoli.
There is no evidence that this was anything but media speculation, but Malta accepts more than its fair share of those fleeing poverty, conflict and poverty in Africa and the Middle East.
The AFM’s maritime and air sections have been kept busy in recent years with a flow of refugees attempting to enter the European Union from North Africa. The events of the soi-disant ‘Arab Spring’ in Tunisia, Libya and Egypt will inevitably increase that flow in the foreseeable future.
a question mark still hangs over the future of one of the country’s two main private hospitals, the 75-bed St Philip’s in Santa Venera, which closed in 2010 and is currently for sale
The relatively large numbers of such migrants arriving in Malta poses another politically sensitive challenge to the public healthcare system. Malta is struggling to find ways to provide for thousands of migrants and asylum seekers, and given the continuing political crises in nearby Libya, Tunisia and Egypt, those numbers seem likely to increase. According to the international aid organisation Medecins Sans Frontieres (Doctors Without Borders), “appalling living conditions and poor access to healthcare contributed to the deteriorating physical and mental health of detainees” at refugee detention centres in Malta between 2008 and 2010. However, according to MSF, Malta’s health services coped well with that overstretch, and an improvement in healthcare provision for asylum seekers and migrants meant that the emergency phase was over by the end of last year. A significant factor was the provision of multi-lingual ‘cultural mediators’ to ease communication between health workers and patients, with the Maltese health authorities creating several posts for cultural mediators at Mater Dei Hospital and at other health centres.
Ultimately, as one of the EU’s smallest members, Malta punches well above its weight in terms of public sector healthcare, international humanitarian aid, and emergency medical evacuation provision. Its unique location between Europe and the Arab world has rarely offered more challenges, but it appears likely that this tiny island state will play a significant role in the reconstruction that must surely follow the tumultuous events of this summer.