Malta Urged to Improve Palliative Care Beyond WHO Minimum

The Medical Association of Malta (MAM) has issued a pointed appeal to national authorities to overhaul the country's palliative care system, warning that Malta currently falls far short of meeting the clinical needs and expectations of its terminally ill patients. The organisation emphasises that Malta must aim higher than simply offering the World Health Organization's (WHO) minimum standard of care.

The Medical Association of Malta reports that the nation currently relies on only two designated palliative care professionals—a single consultant and one resident specialist—to provide services across the entire country. This is a stark contrast to the WHO's guideline recommendation, which calls for a minimum of 12 full-time specialists for a population the size of Malta’s, which currently stands at over half a million.

WHO list falls short for high-income country care standards

In a statement published on MAM’s website, association president Dr. Patrick Sammut emphasized that the WHO’s Essential Medicines List for Palliative Care serves as a foundational guideline intended primarily for low- and middle-income nations. It includes 22 medications intended to provide a foundational level of symptom relief for patients nearing the end of life. However, Sammut stressed that this list should not be interpreted as sufficient for a high-income country such as Malta.

“Malta currently ranks 26th out of 35 in the 2023 Euro Health Consumer Index and prides itself on high standards in hospital care, primary care, and life expectancy,” Sammut noted. “In this context, restricting palliative care to the WHO’s essential list would be entirely inadequate—both clinically and ethically.”

He argued that developed European countries like the United Kingdom, France, and Germany have expanded their palliative formularies to include over 50 medications. These include drugs for managing complex pain, respiratory distress, agitation, seizures, and terminal secretions. Sammut urged Malta to strive for similar standards.

“We must aim higher,” he said. “Ensuring compassionate, evidence-based care for all terminal patients—not just some—should be a national imperative.”

Broader medicine list submitted to government

As part of its advocacy, the MAM has submitted a detailed proposal to the Ministry for Health that includes over 30 additional medications commonly used in advanced palliative care across the UK and EU. These medications have not yet been included in Malta’s official government formulary.

This submission has reportedly led to constructive discussions with health authorities. Sammut said the MAM welcomes the current momentum and sees it as a critical opportunity to build a more equitable and comprehensive palliative care system.

Core challenges: access, location, and staffing

Dr. Sammut was quick to point out that while expanding the list of medications is essential, the greater issue lies in accessibility. The challenges are multifaceted:

Access limited by diagnosis

Palliative care medications in Malta are predominantly available to cancer patients, despite the fact that cancer accounts for only about 25% of all individuals who require such care. The rest—those suffering from conditions such as heart failure, chronic obstructive pulmonary disease (COPD), end-stage liver disease, amyotrophic lateral sclerosis (ALS), and advanced dementia—often endure prolonged and equally debilitating symptoms. Yet, they remain underserved under the current model.

Geographic limitations

Even when medications are available, they are frequently restricted to use in hospital or hospice settings. This poses a significant barrier for patients who are living at home, particularly in rural regions or those with mobility limitations. To truly focus on patient needs, palliative treatments should be accessible within the community, including at local pharmacies and through home-based care services.

Shortage of specialist providers

The human resource issue is equally pressing. “Palliative care is not just about medication—it involves specialist knowledge, holistic care, and compassionate decision-making,” Sammut wrote. A mere two officially designated specialists cannot realistically support the needs of the entire population.

According to the European Association for Palliative Care, a country with Malta’s demographics should maintain at least 12 full-time consultants to provide sufficient support across hospitals, hospices, community settings, and for non-oncology patients. The current shortage places a heavy burden on general hospital staff and family physicians who may lack adequate training in palliative protocols.

Broader debate on euthanasia underscores existing gaps

The national discourse around euthanasia has indirectly highlighted the fundamental deficiencies in Malta’s current palliative care infrastructure. According to Sammut, meaningful discussions on end-of-life choices are only possible after a robust and equitable palliative care system is firmly in place.

“To truly honour the dignity of every person at the end of life, we must be able to look them in the eye and say: we have done everything modern medicine can offer to relieve your suffering,” he said. “Only then can we have meaningful discussions about end-of-life choices.”

A call for a policy shift and collaborative planning

MAM is not simply identifying problems—it is actively proposing solutions. The organisation has urged policymakers and health administrators to collaborate with clinicians to establish and implement a roadmap for reform. Key recommendations include:

• Expanding the national palliative formulary to include a wider range of medications aligned with European standards
• Recruiting and training more specialist palliative care professionals to meet international guidelines
• Establishing a palliative care system rooted in community settings to guarantee fair and widespread access
• Broadening the scope of care to include patients with terminal illnesses beyond cancer
• Embedding palliative care education into broader medical training to improve general awareness and competence

According to the Medical Association of Malta, these changes are crucial to guarantee that individuals nearing the end of life are provided with the thorough and compassionate care they rightfully need during their most vulnerable moments.

The importance of aligning care with human dignity

Ultimately, the MAM’s message is grounded in a moral and ethical appeal. As a high-income nation with an ageing population and a modern healthcare system, Malta has both the responsibility and the means to deliver end-of-life care that is equitable, evidence-based, and respectful of human dignity.

While constructive dialogue with the government is underway, the Medical Association warns that delay or half-measures could result in prolonged suffering for patients and added emotional and logistical strain on families and caregivers.

Conclusion

Malta stands at a critical crossroads in its approach to palliative care. While the nation has made significant strides in hospital and primary healthcare, its end-of-life care system remains limited, both in scope and accessibility. The Medical Association of Malta has clearly outlined the urgent need for reform, calling for expanded medication lists, increased specialist staffing, and a shift toward community-based care that includes patients with a wide range of terminal conditions—not just cancer.

These reforms are not merely administrative adjustments; they represent a moral obligation to ensure that every individual facing the end of life can do so with dignity, compassion, and adequate medical support. As constructive dialogue continues between the medical community and government authorities, the opportunity now exists to create a modern, inclusive palliative care framework that truly reflects Malta’s healthcare aspirations and ethical responsibilities. Failure to act decisively would leave vulnerable patients behind at a time when they most need the system’s support.

FAQs

What is palliative care?
Palliative care focuses on relieving symptoms and improving the quality of life for patients with serious, life-limiting illnesses. It includes pain management, emotional support, and holistic care.

Why is Malta's palliative care system under criticism?
Malta has only two palliative care specialists and offers limited access to essential medications, which falls short of international guidelines for a country of its size and income level.

What does the WHO recommend for palliative care in Malta?
According to the WHO and the European Association for Palliative Care, Malta should have at least 12 full-time palliative care consultants to meet population needs.

Which patients are underserved by current policies?
Patients with non-cancer illnesses—such as heart failure, advanced dementia, or ALS—are often left without sufficient palliative care resources.

Why is access to palliative medication restricted in Malta?
Some medications are only available in hospitals or hospices, limiting accessibility for patients at home or in rural areas.

How does the current system affect general practitioners?
The shortage of specialists places extra pressure on general physicians who may not have specialised training in palliative care, affecting the quality of care.

What has the Medical Association of Malta proposed?
The MAM submitted a list of over 30 additional palliative medications to the government and urged recruitment of more specialists and expansion of community services.

Is this issue linked to the euthanasia debate in Malta?
Yes. MAM believes that before engaging in policy debates about euthanasia, the state must first ensure it offers robust and equitable palliative care options.

Are other European countries ahead of Malta in this area?
Yes, countries like the UK, Germany, and France have palliative formularies with over 50 medications and well-established community care networks.

What steps are being taken by the government?
Discussions are ongoing with health authorities following the MAM's recommendations, but no concrete policy changes have yet been announced.