Ten years on: time for a public health celebration or sober reflection?

Ten years ago Malta was deeply divided into two camps: those in favour and those against membership of the European Union (EU). The referendum was a narrow victory for supporters of membership, and the rest is history. At the time of accession, the health sector was not one of the key areas targeted for debate or scrutiny.1 This may have been due to the fact that European competence in health was limited and Member State competence in matters of health policy was held to be supreme. The potential ‘brain drain’ resulting from the free movement of health-care professionals was highlighted at the time of enlargement.2 While professional mobility is a complex phenomenon, recent analysis of data indicates that although the numbers of doctors from the new EU 12 present in the old EU 15 more than doubled between 2003 and 2007, estimated outflows have rarely exceeded 3% of the domestic workforce.3 Malta was particularly concerned about the potential loss of health-care professionals to other countries.4 Shortly after accession, ∼80% of newly graduated doctors started to migrate annually. This situation called for immediate action and the government set up a Foundation School under the auspices of the UK Foundation Programme. This initiative taken at national level was effective in halting this mass migration. Over the years a strong postgraduate training programme has developed in partnerships with teaching hospitals in other EU countries, and this development was also supported through the European Social Fund. A second major concern for Malta was related to medicines. Major legislative and administrative reforms were required to adhere to the European legislation.5 Despite specific provisions, such as the ‘Cyprus clause’ (Article 126a: registrations are a simplified registration process specifically created to address access in small countries), the number of available medicines in Malta dropped sharply after accession, and market access at affordable prices still remains a significant challenge to contend with to date. The Joint Procurement Initiative being negotiated following the adoption of the Decision on Serious Cross Border Health Threats is a step in the right direction to enhance access and affordability.6 Free movement of patients was already prominently on the agenda in 2004. Malta was concerned that patients would seek care in other European countries destabilizing the national health system, which is reliant on minimum volumes of interventions to sustain certain services. This concern has not materialized to date primarily because Malta has a long history of bilateral cross-border cooperation with England.7 The utilization of this programme has meant that movement of patients to date has taken place through national instruments rather than through the application of EU rules. The recent implementation of the Patients Rights and Cross-Border Care Directive could hail a change in the trends seen to date. An outflow of patients is most likely to be closely followed by an outflow of expertise, which would mean closure of specialist services and reduced access for persons without means to travel overseas.8 On a positive note, the ability to use regional funds for investment in health infrastructure and human resources was an unanticipated benefit. The 2007–2013 Structural and Cohesion Funding Programmes provided Member States with the opportunity to prioritize health investment and ∼1.5% of funding went towards health infrastructure. Malta seized this opportunity to develop a specialized cancer facility using European Regional Development Funds (ERDF), and it is estimated that ∼5.4% of the European Regional Development Funds would have been spent on health infrastructure projects by the end of this funding period. Impetus was also given to the development of national cancer screening programmes for breast cancer and colorectal cancer as a result of the Council Recommendation on Cancer Screening and the subsequent report issued in 2007 highlighting that Malta was one of the only Member States without cancer screening programmes.9 Although this could be viewed as a gentle, but firm, type of harmonization effort, it must be conceded that often such policy triggers are necessary to overcome non–decision-making often evident in small communities with powerful stakeholder interests. Public health professionals have benefitted from the networking and training opportunities provided through the Health Programmes, particularly some of the Joint Actions. The role of the European Centre for Disease Control in providing technical guidance and support was particularly important during the H1N1 pandemic. Malta's health status, which was already more akin to the EU 15 at the time of accession, has continued to improve over the past decade. Over the years, a number of important public heath policy strategies have been developed and adopted including the Non-Communicable Disease Strategy, National Cancer Plan 2011–2015, Healthy Weight for Life Strategy and the Sexual Health Strategy. Although it is not possible to associate the adoption of these plans or the improvements in health status with Malta's membership in the EU, the influence of EU public health policies and programmes on health status and health systems is a research topic that merits attention. To date, from a health perspective, Malta's membership of the EU appears to have a net positive impact. It remains to be seen whether this positive judgement will still hold true if the health system becomes subject to budgetary cuts as a result of the pursuance of economic policy objectives where specific contextual characteristics are not taken into account. The Country-Specific Recommendations derived from the European Semester process aimed quasi-exclusively at addressing sustainability of public finances are worrying examples of European policy, which is threatening to the positive trends in health outcomes seen so far, unless investment in public health and health services is appropriately safeguarded.