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Primary Health Care Reform – Deeds not Words!

 http://sammut.homestead.com/files/mrsammut.jpg18 February, 2000.

Dr. Mario Sammut sent me this article entitled 'Primary Health Care Reform - Deeds not Words!', which was published in the Times of Malta on the 18th February 2000. Dr Mario R Sammut MD is the Honorary Secretary of the Malta College of Family Doctors.

Primary Health Care Reform – Deeds not Words!

During the launch of a Quality Service Charter at Qormi Health Centre last month, the Minister of Health Dr Louis Deguara declared that this reflected the government’s policy that the sector of primary care should be the basis of the health service in Malta (The Times, January 21).   He went on to specify that the success of reforms in the health sector depended on the success of the changes towards a comprehensive primary care service, with full collaboration and cooperation between the services provided by the government and the private sector.

This viewpoint was confirmed by the Prime Minister Dr Eddie Fenech Adami on the 1st February at the inauguration of the refurbished health centre in Cospicua, when he said that the government was committed to improving primary health care to alleviate pressure on hospitals as well as to put more emphasis on prevention (The Times, February 2).

I am sure that no one doubts both these honourable gentlemen re the sincerity of their declarations, but for how much longer is the citizen to hear such statements repeated without seeing anything coming out of them?   I very much fear that in this country we seem to have great difficulty in converting words into deeds, as evidenced by the sequence of events (or lack of them) in the primary health care sector over the past ten years or so.    Please allow me to run through such sequence.

The importance of reform towards the provision of quality in primary health care, both academically and organisationally, was first highlighted in the late 1980’s.   Regarding the academic aspect, a 9-month intensive course for family physicians was conducted in 1987-88 by the late Prof. D Johnson of the University of Toronto, under the auspices of the University of Malta and with the support of the Ministry of Health.   As declared by Prof. E S Grech, former Dean of the Faculty of Medicine and Surgery, it is a pity that the competent authorities at the time did not respond to a detailed report on the development of family medicine in Malta left for them by Prof. Johnson [i].   However, as an indirect result of such course, the Malta College of Family Doctors (MCFD) was founded in 1989, with an emphasis in its statute [ii] on the College’s primary responsibility ‘to encourage, foster and maintain the highest possible standards in family medicine in Malta’.

As regards the organisational quality of primary care, in August 1988 the Minister of Social Policy (then responsible for Health) Dr L Galea wrote to the two doctors’ unions at the time, the Medical Association of Malta (MAM) and the now-defunct Union of Government Medical Doctors, announcing that “this administration intends to provide a truly comprehensive national health scheme, in which a key factor is that of the right choice of the patient to his own general practitioner”, and inviting them to make submissions in this regard [iii].   Here, as described in the WHO publication ‘Health Care Systems in Transition – Malta’ [iv], ‘a major change to the (primary care) system was attempted.   The government at that time wanted to introduce a scheme whereby patients would be registered with a GP of their own choice.   GPs were to be remunerated on a capitation basis and allowances.   The scheme was to be voluntary, (and) not all GPs would be obliged to join.’   However by 1991, as the report goes on to describe, ‘due to a series of problems, the initiative never materialized, the project was abandoned and an opportunity to make a difference to the primary health care service was lost.’

During a symposium organised by the Ministry for Social Policy in 1991 entitled ‘Reforming the Health Services’ [v], the Workshop on Primary Health Care concluded that the most important and urgent recommendation in this area was a comprehensive educational campaign for the public to make effective use of primary care services while avoiding abuse.   Such educational campaign never materialised.

Two years later, the Medical Association of Malta took the initiative in organising a conference entitled ‘Quality of Health Care in Malta – the Way Ahead’ [vi], and the following were the main consensus points following the session on Family Practice:

·         The continuity of care needs to be restored so that a doctor or more likely a small group of doctors are identified as the patient’s carers.

·         Immediate consideration is given to the formulation of an adequate medical record in the health centres.

·         The time has come to institute specific training for Family Medicine … and CME should be actively promoted.

·         Peer review: one of the possible steps could be the formulation of sets of clinical guidelines for common conditions seen in general practice.

·         Pathology practice – a quality assurance programme should be made available for anyone performing laboratory tests outside hospital.

Then, in 1995, the Department of Health Policy and Planning of the Health Division published ‘Health Vision 2000: A National Health Policy’ [vii], which recommended that ‘the Primary Health Care Services will need to be strengthened in ways that will allow for the development of sound doctor-patient relationships and continuity of care, and will evolve from one exclusively providing medical care to clients at time of illness to one of advising, counselling, educating and coordinating all such activities that will help people adopt lifestyles conducive to better health and better quality of life’.

In May 1998, the Malta College of Family Doctors approved its ‘Policy Document on Family Medicine in Malta’ [viii] (drawn up in line with World Health Organisation (WHO) recommendations [ix]), and presented it to Dr M Farrugia, the Minister of Health in the Labour government then in power.   In July 1998, the College sent the Policy Document with a Memo to Political Parties entitled ‘Recommendations for the Future Development of Primary Care in Malta’ [x].   The memo concluded that “any future changes in the primary health care field should include these priorities:

·         The homogenization of private and state-provided primary care services;

·         Full professional autonomy of family doctors;

·         The establishment of a chair in Primary Care within the Faculty of Medicine;

·         Vocational training, ongoing education and specialization opportunities for family doctors.”

'The betterment of primary health care in the community' is the title of section 161 of the 1998 Electoral Manifesto of the Nationalist Party [xi], which states: ‘We commit ourselves to the betterment of primary health care in the community. This means the service provided by family doctors, health centres, pharmacists, nurses and paramedics, team-working at the local level. Reform here is essential. The biggest setback is that patients do not always meet the same doctor when visiting healthcare centres, and so continuity and the personal touch are lost. We will work at finding ways of promoting cooperation between the private health sector and that of the state, to the greater satisfaction of doctors and patients.’

In November 1998, following the election of the Nationalist Party to government, the Malta College of Family Doctors wrote to the Prime Minister [xii] (in reference to the Nationalist Manifesto) as follows:

·         Organisational improvement of structural conditions

“The College agrees that continuity of care and teamwork are two of a number of cardinal characteristics of Family Medicine, together with systematic record-keeping and a cost-effective referral system, working within well-organised practices.   International experience consistently shows that those health systems with a comprehensive and strong general practice set-up go hand in hand with relatively low national spending on health care (ref. World Bank Report, 1990).   Unfortunately, while huge financial resources are allocated for the development of secondary/tertiary care in Malta, primary care remains the Cinderella of medicine and is afforded scant and insignificant attention”.

·         Professional development

“The College believes that education of the family doctor should be reviewed, both at undergraduate level (which at present is practically non-existent), and at postgraduate level through the introduction of vocational and specialist training (in addition to continuing medical education presently provided by the College).   Such activities can only be maintained by an Academic Department of Family Practice within the Faculty of Medicine and Surgery at the University of Malta.   In fact, this ties up with Malta's aspirations to become a member of the European Union, where specialist training in Family Medicine is a requirement for family practice by doctors qualifying after EU accession (ref. EC Council Directive 93/16/EEC of 5 April 1993)”.

On this point of professional development, the University of Malta finally re-entered the field in February 1999.   During a meeting that month with the Prime Minister, the President of the Malta College of Family Doctors Dr D Soler announced [xiii] that the setting-up of a long-overdue University Department of Family Medicine had been included in the Faculty of Medicine & Surgery's Strategic Plan for 1998-2000, and urged that the Cabinet favourably considers a report outlining ‘Proposals for Reform in the Primary Health Care Services’ [xiv] prepared by the College with the Department of Primary Health Care and the Medical Association of Malta.

The latter report was finalised in January 1999 by the Working Group set up on the initiative of the Ministry of Health through the Department of Primary Health Care.   As described in ‘Health Care Systems in Transition – Malta’ [xv], these proposals ‘seek to address the rift that exists between the public and private systems of health care provision and take Malta’s historical, cultural, social and economic context into account.   The principles underlying the reform will be similar to those proposed in 1991, but the details differ having learned from previous experience’.   This WHO report went on to emphasize that ‘the present system of primary care is inefficient and reforms in this sector are urgently required.   These must occur in the wider context of health care reform with particular attention to community support services and an emphasis on health promotion and disease prevention.’

Unfortunately, in May 1999, the MAM and the MCFD were given the disappointing news that the Cabinet had sent back the above recommendations to the Working Group with the message 'think again', apparently due to the country's financial constraints.   In reply, both organisations reconfirmed their “readiness to participate in discussions leading to a reform in primary health care … but requested that the Cabinet provides the Working Group with an indication of the financial resources that would be available for any proposals made.” [xvi]   To date, no answer has been forthcoming to such offer and request.

Therefore, despite:

·         initiatives from professional interest groups (the Malta College of Family Doctors and the Medical Association of Malta) on the

·         recommendations of international organisations (the World Health Organisation, the European Union and the World Bank), and the

·         provision of the necessary support from government and non-government organisations (the Health Division, the Ministry of Health and the University of Malta),

the Nationalist government’s Cabinet has so far failed to “put its money where its mouth was” when still a political party in opposition!

On the 18-20 February 2000, the Foundation of Medical Sciences and the Forum Group (representing the professional medical, pharmacy and nursing organisations) will hold a consensus Conference on the Future of Health Care in Malta entitled ‘A National Agenda for sustainable Health Care in Malta’.   In the Sunday Times of February 13, Prof. F. F. Fenech reminded that “in all debates on health care, the issue of strengthening of primary care … will relieve the demands on the expensive hospital sectors and also reduce the burden of illness”.   He went on to augur that, through and following such conference, “our politicians will act together forgoing narrow political interests in the defence of the sick and suffering, both present and future” [xvii].

In conclusion, may I suggest that the time has come for the ordinary citizen to become more involved in the reform for quality of health care through the lobbying of parliamentary elected representatives (directly or through the media), for the good of the country's health care system and, ultimately, that of the Maltese patient.

Dr Mario R. Sammut MD


[i] Grech E S. Letter to the Editor. Journal of the Malta College of Family Doctors 14:23, 1998.

[ii] Malta College of Family Doctors. Statute. Malta: MCFD, 1990, 1996.

[iii] Galea L, Minister for Social Policy. Letter to the Secretary, Union of Government Medical Doctors. Correspondence, August 1998.

[iv] Azzopardi Muscat N, Dixon A. ‘Health Care Systems in Transition – Malta’. Copenhagen: WHO, 1999.

[v] Ministry for Social Policy, Malta. Symposium ‘Reforming the Health Services’. Valletta, Malta, 10th, 24th March, 21st April 1991.

[vi] Medical Association of Malta. Consensus Statement ‘Quality of Health Care in Malta: the Way Ahead’, 3-4 September 1993. Malta: MAM, 1993.

[vii] Department of Health Policy and Planning. ‘Health Vision 2000: A National Health Policy’. Malta: Health Division, 1995.

[viii] Malta College of Family Doctors. ‘Policy Document on Family Medicine in Malta’. Malta: MCFD, May 1998.

[ix] World Health Organisation. “Framework for Professional and Administrative Development of General Practice/Family Medicine in Europe”. WHO Regional Office for Europe, 1998 (EUR/ICP/GPDV 94 01/PB01/Rev.1).

[x] Malta College of Family Doctors. ‘Recommendations for the Future Development of Primary Care in Malta. Memo to Political Parties.’ Malta: July 1998.

[xi] Nationalist Party. Electoral Programme 1998 “Gid, Fiducja, Direzzjoni”. Malta: PN, 1998.

[xii] Sammut M R, Honorary Secretary, Malta College of Family Doctors. Letter to the Prime Minister of Malta. Correspondence, 11th November 1998.

[xiii] Malta College of Family Doctors. Press release: ‘University Department of Family Medicine to be set up. Proposals for Reform in Primary Care to be presented to Cabinet’. Malta: MCFD, 18th February 1999.

[xiv] Working Group: Department of Primary Health Care, Medical Association of Malta, Malta College of Family Doctors. Outline of Proposals for Reform in the Primary Health Care Services.   Unpublished document, January 1999.

[xv] Azzopardi Muscat N, Dixon A. ‘Health Care Systems in Transition – Malta’. Copenhagen: WHO, 1999.

[xvi] Sammut M R, Honorary Secretary, Malta College of Family Doctors. Letter to the Director General (Health). Correspondence, 9th June 1999.

[xvii] Fenech F F. ‘Health Care Reforms’. Malta: The Sunday Times, February 13, 2000.


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