Malta

Demographic development

Population in Malta was estimated by Eurostat at 520.971 in 2021 and it is expected to grow in the coming decades. The age structure is projected to change significantly.

The percentage of the older population (65 and above) is growing and is projected to increase further, following a similar trend, although less pronounced, than the EU average.  In 2019, the proportion of people aged 65 and over amounted to 19.3 % of the population. It is projected to increase to 27.9 % in 2070.

The old-age dependency ratio (number of people aged 65+ year as a percentage of the number of people aged 15-64 years) is projected to increase consistently from 29.1 % in 2016 (EU:  29.6%) to 55.8 % in 2070 (EU: 51.2%), an increase of 26.7 percentage points (EU:21.6).

Public expenditure on long-term care (0.9 % of GDP in 2016) is relatively low compared to the average EU level of 1.6% of GDP. 0.7% of GDP is spent on in-kind benefits (EU: 1.4%), while 0.2% of GDP is provided as cash-benefits (EU: 0.2%). Under an assumption of no policy change, it is expected that public expenditure on long-term care as a share of GDP would rise from 0.9% to 2.3% between 2016 and 2070, remaining below EU average (EU-27: 1.6%-3.1%). The impact of a progressive shift from the informal to the formal sector of care in Malta would entail an estimated increase by 179 % in the share of GDP devoted to public expenditure on long-term care (128% on average for the EU27).

Life expectancy at birth with 84 years for women and 79.7 years for men is above the respective EU averages of 83.3 and 77.9 years in 2015. Healthy life years expectancy is very high with 74.6 years for women and 72.6 for men in Malta versus 63.3 and 62.6 in 2015 in the EU. The percentage of the population in 2015 having a long-standing illness or other health problem was lower than in the Union (29.2% in Malta against 34.2% in the EU). The percentage of the population indicating a self-perceived severe limitation in daily activities stands at 2.5%, which is considerably lower than the EU-average (8.1%).

Total expenditure on health as a percentage of GDP has increased over the last decade (from 9.0% in 2005 to 9.8% in 2014), though remaining below the EU average of 10.2% in 2015. The Maltese public health care system ensures universal coverage. It provides a comprehensive basket of services to all residents who are covered by the Maltese social security legislation, and also provides necessary care to groups such as irregular immigrants and foreign workers who have valid work permits. There are no user charges or co-payments for health services. The private sector acts as a complementary mechanism for healthcare coverage and service delivery. Overall, healthcare appears well accessible, as self-reported unmet needs for medical care are very low.

Long-term care system

Malta has a mixed system of care, involving state, church and private institutions. Staying at their home and thus remain in the community is the preferred option among the Maltese. The state promotes this preference by providing a number of services and finances part of the cost of having a member of one’s family act as a carer, or the cost of an outsider recruited for this purpose on a full-time or part-time basis.

In view of Malta’s size, all the major administrative tasks are managed centrally, by the Ministry for Senior Citizens and Active Ageing. Local Councils, of which there is one in every town and village, act as a point of contact for services. Some of them provide services like a day centre, respite care services, night shelter services and cultural activities like outings for older people. All Maltese have a legal right to LTC if they need it, and there is no distinction on the basis of creed, income, race or any other factor.

Malta does not have a specific insurance fund to cater for LTC expenses. Malta’s social security system is based on contributions made by all people in gainful employment during their working life, which is meant to cover them for unemployment, social security and health care requirements. All the money collected from these contributions is paid into one fund, known as the Consolidated Fund, to which all government revenue is credited, and in turn from which all government expenditure is paid.

In Malta, children do not have a strict legal obligation to look after their older parents, although the moral obligation to do so to one’s best ability is universally felt and generally followed. This results in a high incidence of informal care. Caring for the dependent relatives is traditionally considered as the responsibility of women, even if men are also likely to be involved, without disrupting their working pattern.

However, the demand for long-term care services has been growing due to the ageing of the population and the intensification of labour-market participation of women. Since the mid-1980’s, issues related to long-term care have been given more attention. Long-term care capacity has already been expanded in recent years. However, although public capacity for institutional care (i.e. residential homes) is around the EU average, and provided by the government at both central and local level, it remains insufficient to meet the demand. The private sector has been developing a complementary offer of long-term care services. Home-based services have also expanded in recent years. Besides, it is to be noted that more affluent families tend to hire migrant workers to provide care to their dependent relatives. In particular, Filipino carers are employed under private regular work contracts.

Acknowledging the importance of active and healthy ageing in the community, a range of community care services have been developed, aiming at enabling the elderly to continue living at home and/or in the community. However, most of the public spending on long-term care is devoted to institutional care in-kind services, while only 15% is spent for LTC services provided at home (EU: 28%).

Since 2017, quality of the LTC has been improved through the implementation of the Standards of Care Quality Charter. Quality has also been improved through the formal training facilities that have been developed. Both the University of Malta, the Malta College of Science and Technology (MCAST) have launched a varied programme of certified training for potential carers.

 

Accessibility, affordability and quality of long-term care services

Eligibility for long-term care in state-run institutions is granted to persons over 60 years and/or those with a disability that leaves them unable to live autonomously at home. For all cases, eligibility is determined by a multi-disciplinary evaluation.  Access is theoretically open to all, on the basis of income, but political patronage and connections are known to have an influence. More importantly, those who do not manage to be admitted in a public long-term care facility find it extremely difficult to afford either Church run or private services: the cost of these eats very considerably into pensions, the highest of which are lower than the minimum wage. Even those elderly people in state-run homes face financial difficulties, since they have to contribute between 60% and 80% of their pension entitlements, plus 60% of any other income.

Qualitative research shows that families are generally very satisfied with the service of privately employed migrant carers, but such a costly arrangement is out of reach for the majority of the population. Services in long-term care have been significantly improved, both at local and national level, but it is not clear if qualitative standards are achieved evenly across the territory.

 

Recent reforms in long-term care

Malta is implementing a National Strategic Policy for Active Ageing (2014-2020), based on three distinct pillars: active participation in the labour market, social participation, and independent living. Informal care is addressed in the second and third pillars:

• The second pillar focuses on financial security and active participation in society of the elderly, encouraging in particular volunteering, active grandparenthood, and involvement in the community. The policy promotes lifelong learning, offers support to informal carers and foster inter-generational solidarity.
• The third pillar promotes independent living, and health prevention and promotion within the community sector. It brings together various services, in charge of acute and geriatric rehabilitation, psychiatric mental health and wellbeing and community care services. It promotes age-friendly communities, capable of ensuring a good quality of life for older people within society.

Community services, including respite service, are being reinforced to support older adults to continue living in their own homes. Innovative financial support models for personal care at home have been introduced. Several intergenerational programs are held.

Besides, the government has also undertaken various measures to enhance long-term care and services for the elderly. These measures include: (a) national minimum standards for residential homes to ensure adequate environment and care of residents; (b) the upgrading of the national “Telecare” service to “Telecare Plus”, which now offers valuable add-ons and also the upgrading of the pendant to a ‘smart accessory’; (c) a ‘carer at home’ programme that provides older persons with full time carers to support them to live in the community. The majority of care homes were also upgraded to nursing homes, have also undergone refurbishment and have been upgraded with wi-fi facilities.

Moreover, a National Dementia Strategy is being implemented, including: (a) the setting up of a dementia intervention team to further support persons with dementia in the community; (b) the opening of a dementia day activity centre at St Vincent de Paul Residence for the elderly and a dementia centre in Gozo, the second largest island of the Maltese archipelago; and (c) the introduction of a 24/7 dementia helpline service (d) the setting up of a National Commission on Dementia. Moreover, a pilot programme on dementia friendly communities has been running since January to December 2016, during which booklets on dementia were published, targeting both the general public and informal carers.

Number of carers

As a result of the lack of relevant statistical data and research on care and caring related issues in Malta, there is no official data regarding the number of informal carers. However, according to the European Quality of Life Survey 2016, the proportion of people taking care for a disabled or infirm family member, neighbour or friend aged 75 or over at least several days a week is 9 %, close to the EU average of 8 %. 7% of the population is taking care of a dependent under 75 (EU  9 %).

The prevalence of informal care within the working population is comparatively low in Malta, with 4% of people in employment managing care for a dependent over 75, against 6 % in average in the EU.

There is a trend towards a further decrease in access to intra-family care, which is directly related to the increase in the number of women employed in various sectors of the economy. This, together with dwindling family size, and the increased mobility of young couples, is creating a lot of pressure on ‘who’ is to provide LTC for older parents.

The ‘caring gap’ between men and women is more marked than in the EU in average.  Indeed, in Malta, 12 % of women (EU:9%) compared to 5 % of men (EU: 6%) are involved several days a week in caring for the 75 plus in Malta. When it comes to care given to dependents under 75, 9% of the Maltese women are involved several days per week (EU:10 %) compared to 5 % of men (EU:7%).

Informal care is very extensive in Malta: in 2016, as many as 35.8 % of the informal carers reported to be providing more than 20 hours of care per week (as opposed to only 22.2 % at EU-27 level); here, the proportion of men is slightly higher than that of women (37.6 % vs. 34.7 %).

Multisectoral care partnerships

The National Strategic Policy for Active Ageing (2014-2020) encourages cross-sectoral cooperation (see below).

Access to respite care

Since 2017, the ‘Respite at Home’ service in Malta provides formal carers of elderly people with the help of a qualified professional carer at-home, to relieve them temporarily from the burden of care. The Respite at Home service is implemented at national level and offers support with activities of daily living such as bathing and dressing. It Is aimed at older persons with dementia, or other cognitive impairment and support needs. Each demand is assessed or reviewed by a multi-professional team that decides on the frequency and delivery of respite care considering the needs of the family.

Carers’ leave

Carer leave for family raisons is granted to employees from the public sector only, and might be used to provide long-term care (See above).

Social inclusion of carers, access to education and employment

In Malta, the vast majority of carers choosing to provide long-term care to a relative to the detriment of paid employment, do not receive compensation, to the only exceptions of single or widowed people, who may be eligible for a carer’s pension or social assistance for carers. In both cases, the amount granted is less than the minimum wage, and it is subject to a strict test of one’s income and assets. Carer’s pension is only granted if the dependent is bedridden, while social assistance is given even if the dependent is not bedridden. At present, only 90 individuals have successfully qualified for a carer’s pension.

In January 2016, a new pilot scheme was launched to provide financial assistance for families willing to hire a carer to address the caring needs of an elderly family member, instead of having the person taken care of in a residential setting. The scheme is open only to 1,500 people.

Recognition and definition of carers

While the recent policy reforms contain a series of measures geared to support informal carers, a comprehensive strategy recognising and defining carers is still missing. One of the challenges faced in Malta is to ensure a comprehensive support to carers likely to tackle the gender care gap.

Identification of carers and assessment of their needs

Respite and support services for informal carers are provided through benefits in-kind via community services and the “Commcare” unit, which provides assessment and case management services via a team of nurses, health professionals, social workers and care workers who provide services to clients that are housebound.

Access to information and advice

As part of the National Strategic Policy for Active Ageing (2014-2020), several information and communication training programs are held to support digital inclusion, as well as to train informal carers of older persons and persons with dementia.

Those doing voluntary or informal work in LTC have few opportunities to up-skill their work or to have their skills and experience formally recognised in order to assist them in becoming LTC professionals. In 2017, a specialised course for anybody interested to apply, inclusive of theory and practice in the care of older people was offered through the University of Malta.

Work-Life Balance

When it comes to Work-Life Balance measures for carers, employees’ situation varies depending whether they are working in the private or public sector.

In the private sector, there is no legal provision facilitating working carers’ work-life balance.  This doesn’t prevent employers from voluntarily accommodating the needs of those workers, in order to help them balance their paid work with their caring obligations, but only a limited number of them do so. In 2013, only 5.9% of employers from the private sectors provided flexible working arrangements for those caring for elderly relatives.

On the other hand, employees in the public sector/public administration are entitled to a set of family-friendly measures (reduced working hours, telework, flexitime, donation of holidays between colleagues, special leaves and career break), which are not accessible to employees in the private sector. Although these measures are not specifically intended to assist workers with long-term care responsibilities, they can be used in such situations. The exact level of take-up of these measures by working carers is not available.

• The 2021 Long-Term Care Report, Trends, challenges and opportunities in an ageing society, EC 2021
• Adequate social protection for long-term care needs in an ageing society, European Commission, Social Protection Committee, 2014
• The 2018 Ageing Report, Economic and Budgetary Projections for the EU Member States (2016-2070), EC, 2018
• Eurofound, European Quality of Life Survey 2016, Data visualisation, accessed on 03042020 https://www.eurofound.europa.eu/data/european-quality-of-life-survey
• European Semester, Country Report Malta, Commission Staff Working Document, 2020
• Ageing Europe, Eurostat https://ec.europa.eu/eurostat/cache/digpub/ageing/ accessed on 03/04/2020
• ESPN Thematic Report on Challenges in Long-Term Care, Malta, EC, 2018
• ESPN Thematic Report on work–life balance measures for persons of working age with dependent relatives, Malta, 2016
• Malta Health Care & Long-Term Care Systems – An excerpt from the Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability, Country documents, 2019 Update, EC, EPC, 2019.
• Malta: Country Health Profile, OECD/European Observatory on Health Systems and Policies (2019)