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 …