34% of Malta’s health bill paid from people’s pockets

Out-of-pocket spending as a share of total health spending in Malta in 2018 was 34.3% – the fourth highest proportion in the EU and more than twice the EU average, a recently published OECD ‘State of Health in the EU’ report reveals.

Government or compulsory schemes in the EU as a whole account for nearly 80% of all health spending, but in Malta, government spending accounts for 64% of the total expenditure on health.

This shows that a good deal of Maltese make extensive use of private health providers as well as retail pharmaceutical spending.

Voluntary health insurances account for only 2.2% of health spending in Malta, compared to 5% in the EU.

Spending on outpatient care accounted for the largest share of out-of pocket (OOP) spending, with the OECD report attributing this high share to “sociocultural reasons”.

“Maltese people with a certain level of income and education have traditionally sought care from private practitioners,” the report says, finding that many people seek outpatient care directly from private specialists without a referral “often to circumvent long waiting lists for certain specialties in the public sector.”

But the report warns that this is “essentially creating a de facto two-tier health system”.

Despite the greater reliance on the private sector for a number of health services, the universal coverage by the State contributed to Malta having the lowest reported un-met needs for medical care in the EU, due to cost, distance or waiting times, with little difference between high-income and low-income groups.

But the report does indicate a degree of health inequality.

89% of the Maltese population in the highest-income quintile (20%) reported being in good health, compared with 58% of those in the lowest-income quintile. “These income-based disparities were much larger in Malta than the EU average.”

Malta’s NHS covers a broad benefits package, with public healthcare services and emergency dental care available free of charge to entitled individuals. Children under the age of 16, police and armed forces personnel and those on low incomes are also entitled to free elective dental services, prostheses, glasses and hearing aids. The rest of the population must pay out of pocket for elective dental care, which explains Malta’s low share of public spending on dental care.

But despite the widespread availability of free services, private general practitioners (GPs) account for approximately 70% of primary care visits, with many patients opting to attend private practices – where they can choose their physician and set appointments – rather than public clinics which, in the main, operate on a walk-in basis.

Malta has also registered the largest growth rate in total health spending in the EU in the past decade; and the third highest growth per capita in health spending, behind only Bulgaria and Romania. Health spending per capita (€2,646) and measured as a share of GDP (8.8 %) in 2018 nevertheless remained below the EU averages.

Malta’s strong economic performance prior to the COVID-19 pandemic has seen rising health spending absorbed by high economic growth, so that total health spending as a proportion of gross domestic product has declined slightly over the past five years.

Second highest life expectancy

Life expectancy in Malta was 82.6 years in 2020 – the second highest in the EU and two years higher than the EU average.

Since 2000, life expectancy in Malta has risen by 4.1 years, which is higher than the average increase of 3.3 years in the EU. Most gains in life expectancy occurred between 2000 and 2010, with an overall increase of 3.0 years. Life expectancy gains slowed in the following decade, with an increase of 1.1 years, although this was above the EU average of 0.8 years.

Following the outbreak of the COVID-19 pandemic, life expectancy temporarily declined by 0.3 years between 2019 and 2020. This was nevertheless below the average decline of 0.7 years seen across the EU as a whole.

Men in Malta were more affected than women: life expectancy fell by 0.4 years between 2019 and 2020 for men but remained unchanged for women.

Overall, the gap in life expectancy between men and women is lower than the EU average, with women living on average 3.8 years longer than men, compared to the EU average of 5.6 years.

The country profiles included in the report are the joint work of the OECD and the European Observatory on Health Systems and Policies, in cooperation with the European Commission.

Distribution of health out-of-pocket spend

Overall share of health spending