Primary health care reforms in Malta : an analysis of the policy process

Abstract

Background: The World Health Organisation has repeatedly encouraged the development of primary care, viewed as an essential component for health systems to fulfil their core objectives. However, the Maltese health system is to date relatively weak in terms of primary care performance. Historically, several initiatives to reform the Maltese primary care system yielded limited results. The purpose of this study is to analyse the local policy-making process in primary care spanning the last six decades. Objectives: The objectives of the study are 1) to understand the history and background of primary health care policy in Malta, 2) to explore the factors contributing to the success and/or failure of primary care policy proposals and 3) to reflect on past local primary care policy in order to provide foundations for relevant future policies. Methodology: This qualitative case study employed a snowball sampling technique. A self-designed tool was utilised to conduct semi-structured interviews. Triangulation of results was achieved through documentary analyses. Results: Seventeen interviews were conducted yielding a response rate of 81%. A new conceptual framework based on Kingdon’s theory combined with an inspired concept of actors from Sabatier’s theory was devised as the analytical framework. The attempted reforms studied include: the 1987-1993 family doctor scheme, the 1999 proposals in improving primary care services, the 2008-2010 doctor of your choice scheme and the 2013 public sector contractual agreement. The main focus of attempted local reforms revolved around implementing a patient registration scheme in order to introduce a gatekeeping role. Despite being very close in achieving such a system in the 1987-1993 initiative, all these efforts were futile and such a system was never implemented. Moreover, participants elicited how the ten-year medical-political dispute influenced all subsequent primary care policy negotiations. The sensitive nature of health in a locally highly charged political context was perceived to have dominantly shaped primary care policy-making throughout the years. Findings further revealed how different stakeholders shifted ground between one attempt at reform and another, highlighting the relationship of veto players in policy-making processes. Conclusions: This is the first study of its kind to have been attempted locally. The obstacles in reforming the Maltese primary care setting are mainly perceived to be political and financial factors. Interviewees suggested the importance of formulating policy according to local contextual needs and circumstances rather than based on what is observed in other countries. The importance of creating and implementing gradual, subtle changes was emphasised in order to minimise resistance. It is recommended that promoting public involvement and aiming for innovative approaches to render the sector attractive for young newly qualified doctors who seem to hold the potential for future improvements in the Maltese primary care sector, are actions that should be pursued. Hence, key implications suggest to meticulously include all stakeholders from initial policy formation stages and to invest more efforts in long-term, culturally and contextually appropriate sustainable policy goals.