It was obvious that Malta's public health service needed rethinking from the very start of this legislature.

Therefore, in 2013, the whole health service was put under the microscope for analysis. Its financing, human capacity building, technological infrastructure, macro and micro management and best clinical protocols were looked at in detail by teams of experts.

The objective of this brainstorming exercise was to obtain a realistic multidimensional snapshot of the situation. My intention was to spearhead the completion of a robust comprehensive plan for a sustainable health system which addressed immediate challenges in real time without compromising long-term sustainability. 

From the outset, the challenge looked daunting but surmountable. Obviously, coming from the private sector, I couldn't help noticing the deep rooted accepted practices which rendered the system vulnerable to abuse in all its forms. I knew there was no magic formula but I also knew that perseverance, common sense and hard work, enriched by thinking outside the box, were the elements that could make the difference.

The main bones of contention then, were to:

• implement the 2013 budget prepared by the previous government, set the ground work for a 2014 budget and work within a system of inadequate and mismanaged finances that did not match the true costs of established operations and that of new introduced services
• • to co-ordinate effectively the different levels of public health care services and integrate one comprehensive National Public-Private Health Care Mix for Malta and Gozo
• tackle the EU Country-Specific Recommendations for Malta's health sector that may be summed up as 'the pursuit of healthcare reforms to increase the cost-effectiveness... in particular by strengthening public primary care provision'
• deal immediately with the pending EU Directives by updating The Medicines Act; introduce Indemnity Insurance and the Transborder Directive
• schedule the PL electoral manifesto's 60 health promises in a deliverable matrix so that these could be implemented within a four-year period.
• implement the operations of the Mental Health Act and The Embryo Protection Act
• look into and fast track the workings of EU funded projects, particularly that of the Oncology Centre, and prepare for new applications to be forwarded for EU structural, innovative and ESF funds
• seek short-term and long-term solutions to ongoing people's expectations for better acute and chronic bed management; waiting lists for operation, out patients and investigations; and A&E department's work load
• change the attitude and motivate a multi-polarized team of 8,300 employees where health workers' conditions of employment, working in the same line of duty, are different from each other as well as to fill in vacancies of health care professionals in the department.

With these clear aims in mind a team of health care providers and I worked hard, in the full knowledge that the health service did not only need short-term fixes but also solution oriented long-term planning. 

By the end of March 2014, the following policies had either been put into place or were taking shape: 

• the concept of health sustainability, accessibility and quality care as part of a comprehensive legal frame work in The Health Act
• finalisation for a first time ever of the laborious process of establishing the costs of each 'free' service
• standardisation of our present health outcomes with a WHO template and initiation of a process which would lead to achieving population health goals by publishing for consultation a National Health Strategic System for 2015-2020
• pursued a process of simplification and cost benefit analysis exercises, instil a workable approach to corporate management and install more best clinical protocols as standard practices.
• issued white papers on food supplements and the pharmacy of your choice scheme and finalized their outcomes, through public and stakeholders consultations
• improved the value down the supply chain of medicines by simplifying the format of contracts, centralizing to one medical store, and by starting the implementation of a more ideal inventory system while improving distribution.
• consolidated a process for improving ehealth and started the electronic conversion of old medical records,
• worked through the day-to-day teething problems in the building of the Oncology Centre, in the drawing of the migration plan, re-negotiating a contract to have 2014 radiotherapy machines, build a professional human capacity resource and also opened a chemo therapy suite in Gozo,
• initiated the ongoing process to introduce new protocols in primary health care services which empower patients to cherish their wellness and planned the way forward for the modernization of health centres and peripheral clinics, starting off with Rabat Health Centre
• overviewed the workings of Public Health Directorate and Occupational Health and Safety Authority
• consolidated Public-Social Partnerships
• re-negotiated a bilateral health agreement between Italy and Malta and drew up a workable agreement between Israel and Malta in National Preparedness, Oncology and Rehabilitation. Addressed Malta's concerns in favour of the anti-tobacco measures pursued by the EU
• coordinated with the University of Malta the opening of a post-graduate orthodontic degree, and with Barth's Medical School to open a satellite university in Gozo
• addressed 34 per cent of PL's health electoral promises
• forged a bipartisan approach to health legislation and policy frame work.

It has always been my firm opinion that the health of a nation's citizens is the responsibility of each and every ministry, since one can hardly think of any one policy emanating from whichever ministry which would not impact the social, mental or physical well being of a citizen. Of particular relevance are the Social Policy and Environment Ministries, though as I said not one ministry can be exempted of its responsibilities to uphold the nation's state of health. 

It follows therefore that it is erroneous to believe that the people's state of health increases in direct proportion to the Health Ministry's financial or other resources. Any policy that undermines people's state of health directly or indirectly, together with any policy that does not protect the individual from conception to old age, has unlimited negative reverberations on the efficacy of any financial budget dedicated specifically to healthcare. It is common knowledge that safeguarding people's health through promotion of healthy living in a clean, safe environment is by far the most effective way to drive down healthcare cost and drive up sustainability of the services.

It is a fact our nation's health is significantly sustained by out-of-pocket payments and that a Public-Private Health mix is not only a choice but a relief to the Treasury. More than anything else, we have to quantify Malta's annual health spending as an ideal percentage of GPD on a par with what is expected by international standards. It is imperative that we ensure that operational (benefits) expenditure always matches the real needs as reflected by our demography, and that economic governance in the health sector is achieved by a bigger emphasis on health prevention. 

A greater added value may also be achieved if the public-private health care system and public-social partnerships are coordinated to cooperate in synergy. It is unfortunate that they are at times perceived as competitors to public health care.  On the contrary, they complement 'free' health care symbiotically and if this partnership is used wisely they will ensure better accessibility to timely healthcare, and saving of more lives.

Finally, I must state that we also need a radical change, from top to bottom, of our cultural attitudes so that we abolish the ill effects of the much advertised concept of 'free' public health, which we all know is not 'free' at all, the partisan political bickering, the lack of coordinated team work between some professionals, resulting in much duplication of work, the questionable ethics and values of certain unions, the unbecoming behaviour of a minority of health care workers, the occasional exaggerated expectations of free health care by certain individuals when there is no entitlement for a benefit which is requested, and the over dependence of our health care system on Community Chest Fund and other such entities to augment the health budget to uphold the right to health.

Having said all this, it is simpler to state that national health care succeeds with every potential patient that is prevented from becoming one; it succeeds with every single patient who gets timely treatment for an ailment; it succeeds with every healthcare professional who harbours 'ownership' of the system, and can realise his / her full potential in the profession; and it succeeds when cost of treatments given loyally reflect realistic costs and achieve expected results. Our healthcare system can boast of success when we are all assured that we will be assisted as necessary to live in dignity to the end.

Dr Farrugia is a medical doctor, a Member of Parliament and a former health minister