Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694840293109.pdf (Malta)
L-ERBATAX-IL LEĠIŻLATURA P.L.

0114 Dokument imqiegħed fuq il-Mejda tal-Kamra tad-Deputati fis-Seduta Numru 5 tas-16 ta’ Mejju 2022 mid-Deputat Prim Ministru u Ministru għas- Saħħa.

___________________________ Raymond Scicluna Skrivan tal-Kamra FTEHIM TA’ KOORDINAZZJONI BEJN IL-GVERN MALTI U L-GĦAQDA DINJIJA TAS-SAĦĦA *151.
L-ONOR MARK ANTHONY SAMMUT staqsa lill-Deputat Prim Ministru u Ministru għas-Saħħa: Jista’ d-Deputat Prim Ministru u Ministru għas-Saħħa jippubblika u jqiegħed fuq il-Mejda tal-Kamra l-Ftehim ta’ Koordinazzjoni li ġie rapportat li ġie ffirmat bejn il-Gvern Malti u l-Għaqda Dinjija tas-Saħħa fl-4 ta’ Marzu, 2022?

10/05/2022 ONOR.

CHRIS FEARNE: Ninforma lill-Onor.

Interpellant li qed inpoġġi fuq il-Mejda tal- Kamra l-ftehim imsemmi minnu.

Seduta Numru 5 16/05/2022 ~ .

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pq ', I s I I MEMORANDUM OF UNDERSTANDING ('MOU') BETWEEN THE WORLD HEALTH ORGANIZATION AND THE MINISTRY OF HEALTH OF THE REPUBLIC OF MALTA REGARDING THE COUNTRY COOPERATION STRATEGY ('CCS') MEMORANDUM OF UNDERSTANDING ('MOU') ,· THE WORLD HEALTH ORGANIZATION AND THE MINISTRY OF HEALTH OF THE REPUBLIC OF MALTA REGARDING THE COUNTRY COOPERATION STRATEGY ('CCS') The World Health Organization and the Ministry of Health of the Republic of Malta hereinafter referred to as "Signatories", reaffirming their common intention to co-operate towards the attainment of the objectives stated in the Constitution of the World Health Organization (WHO) have reached the following understanding: PARAGRAPH 1 Country Cooperation Strategy The attached Country Cooperation Strategy (CCS) should serve as a medium term framework to guide cooperation between the Signatories.
PARAGRAPH2 Financial and administrative arrangements The implementation of the CCS will be subject to the availability of sufficient financial and human resources for that purpose, as well as each Signatory's programme of work, priority activities, internal rules, regulations, policies, administrative procedures and practices.
Each Signatory should cover the costs related to its participation in meetings and other activities based on the CCS and will be solely responsible for the manner in which it carries out its part of the collaborative activities under the CCS.

PARAGRAPH3 Duration The present Memorandum of Understanding comes into effect from the date of its signing.

The Signatories may review and amend any part of the present Memorandum of Understanding and hence of the CCS by mutual consent in writing.
This Memorandum of Understanding remains in effect for as long as the CCS is in effect, namely for the period 41h March 2022 to 3rd March 2026.

PARAGRAPH4 Legal status of the CCS The present Memorandum of Understanding does not constitute an international agreement that binds the Signatories under international law and does not affect their rights and obligations under bilateral or multilateral Treaties and Agreements to which they are or may be a Party.
Nothing in or relating to this Memorandum of Understanding shall be deemed a waiver of any of the privileges and immunities enjoyed by WHO under national and international law, convention or agreement and/or as submitting WHO to any national court jurisdiction.

PARAGRAPH 5 Differences in interpretation or application The signatories should resolve any difference in the interpretation or application of this memorandum amicably through negotiations or consultations.
Signed in Valletta, Malta on 4th March 2022 in two original copies, in English.

Signed by: For the Minist1y for Health of the Republic of Malta ~?e!

:~ Hon Chris Feame Deputy Prime Minister and Minister of Health Date For the WHO Regional Office for Europe Dr Ha: Kluge (_ Regional Director } ~ I Date WHO-Malta Country Cooperation Strategy 2022-2026 1.
INTRODUCTION The Country Cooperation Strategy 2022-2026 (CCS) aims to guide the application of WHO's expertise, comparative advantage and WHO's global and regional strategic priorities as set out in the Thirteenth General Programme of Work and aligned with the core priorities of the European Programme of Work (2020-2025) ''United Action for Better Health" CEPW), and priorities determined by the Government of Malta.
This brief, concise country strategy is designed to identify the exact nature of WHO's planned cooperation and contribution to agreed outcomes under the following broad strategic priority areas: Enhancing Universal Health Coverage and Promoting Health and Well~ Being with a focus on: ~ Health care workforce planning - Digital health - Non~communicable diseases (NCDs) prevention and management: and the role of social determinants of health with a focus on mental health, childhood obesity - Quality of care and patient safety - Access to medicines - Lessons learnt for better wbole-of·government approach to population health and well-being - Strategic leadership for health and sharing of experiences through the Small Countries network and the Malta WHO collaborating Centre on Health Systems and Policies in Small States.
From this point forward, the CCS will serve as the strategic framework taking forward WHO's collaborative work with Malta; it will provide a high~level overview of WHO's role and broadly outline a results-based planning and programming process for the joint implementation of each of the identified strategic priorities of Malta's CCS.

Central to the implementation of the CCS will be a coherent One-WHO approach interacting with a horizontal and vertical whole-of-government approach.
Underpinning WHO's work is a focus on strategic policy dialogue and joint leadership for health.
As a small island state facing unique challenges, Malta is able to share relevant experience during strategic policy dialogues, as despite its size and limitations, it has always been forward~ looking and has taken the lead in various initiatives, proposals and successful collaborations- with other small countries, bilaterally, within the EU, and within networks, as well as regionally, gaining experience and recognition as a leader in this regard.
Signalling WHO's commitment to achieving impact in every country, the CCS model provides a clear results framework guide for monitoring and evaluation.

Recognizing the joint responsibility and accountability of WHO and the Government to improve the health and wellbeing of Malta's population, and at the same time aiming to contribute to improving regional and global health, the CCS will be monitored and evaluated jointly at mid-tenn and in preparation for the negotiation ofthe next ccs.
In conclusion, the CCS as the principal strategic instrument designates the main domains in which WHO will focus its collaborative efforts and resources to support and work with Malta over the next five years.

It does not address the full range of WHO activities and the Organization remains committed to responding to new needs as they arise.

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COUNTRY CONTEXT 2.1 Political, social and economic context Malta is a parliamentary representative democratic republic, where the Prime Minister is the head of Government.

Executive power is exercised by the government, while legislative power is vested in both government and parliament.

Malta has a strong legislative framework relating to public health regulation and enforcement as well as a strong governance framework related to public health policy.
Malta is one of the smallest and most densely populated countries on the globe.

Malta has the lowest fertility rate in the European Union (EU), with 1.14 births per woman recorded in 2019, falling below the EU average of 1.53 births per woman in 2019.

Populatioo growth and movement away The current population stands at 516,100 as at 2020, with an ever-growing proportion of persons over the age of65.
Over the past five years, another age cohort has expanded greatly -young adults between the ages of25 and 35- due to the expansion of the foreign workforce which has grown considerably as a result of economic growth.

The two populations have different specific needs in terms of health care, with an ageing population requiring mostly non~communicable disease related care, whilst young adults require more primary care, sexual health, obstetrics and mental health services.
Migrant workers tend to be from both EU countries and third countries.

Migrant workers tend to be hard to reach in tenns of communicating the need for preventive care and this presents challenges, especially in obstetrics, where migrant mothers tend to present to obstetric services at a late gestational age.
Malta's migration challenges therefore include the legal migrant workers who have their own specific needs and interact less with preventive care, and the longer established population of migrants reaching Malta through irregular migration.

These populations remained relatively stable during the COVID-19 pandemic, with little inflow or outflow, possibly some net outflow amongst legal migrant workers.
Nonetheless, numbers of refugees and asylum seekers remain significant, and many are known to be more prone to physical or psychological challenges.

These challenges became harder during the pandemic as the high prevalence of CO VID-19 amongst boat migrants in highly precarious conditions necessitated quarantine of these migrants on arrival.

In some cases, up to 60-70% of migrants on specific boats developed COVID-19 before or after arrival during summer 2020 and 2021.
In recent years, Malta has served as an EU entry point for migrants and refugees fleeing conflicts.

In 2020, just over 2300 people were rescued at sea and disembarked in Malta with just over 800 arrivals in 2021, a fourth of the number of arrivals in 2019 (UNHCR, 2022).

Common health problems among migrants and refugees are gastrointestinal and respiratory disorders, diabetes, hypertension, pregnancy-related complications, and physical and psychological trauma.
Some also contract infectious diseases during their harrowing journey from their home countries or may be affected by conditions endemic to their country of origin such as tuberculosis or HIV.

Malta's health system in general provides good population coverage, including for refugees and asylum seekers, while efforts are being made to tackle gaps due to communication or cultural barriers.
It is difficult to predict whether, with easing of border controls once the pandemic is controlled, Malta will experience a spike in migrant arrivals- both legal and irregular.

2.2 Health and Equity Situation Life expectancy in Malta is high, but income-based disparities in health status persist.

Strong public health policies contribute to low levels of preventable mortality, and deaths from treatable causes have declined substantially in recent decades because of improved health system performance.
Further reductions in cancer mortality are targeted through improved and earlier access to primary prevention and treatments and improved care integration.

Obesity rates among adults and adolescents in Malta are the highest in the EU with 29% of adults being obese.

Recent legislation regulating advertising and food provision in schools, along with inteNectoral investment to promote a healthy lifestyle and a culture of physical activity, aims to help tackle this major public health challenge.
Prevention efforts will continue to be prioritized and strengthened through training of health professionals and encouraging citizens to improve their own health and well-being, giving due consideration to social detenninants of health.

However, particularly following the pandemic circumstances which seem to have further impacted levels of overweight and obesity, an even stronger whole-of government, whole-of society commitment and approach is required to combat this growing public health concern.
Nevertheless, public health has developed several strong links with various other parts of government as part of the COVID- 19 response, which links should prove highly useful for better investment in prevention, if well nurtured.

Life expectancy at birth for Malta has increased substantially since 2000, reaching 85.3 years in 2020, which is among the highest in the EU and globally.

Life expectancy at birth for Malta's female population is 82.6 years and 79.8 years in men (Eurostat).
Life expectancy in Malta fell by 0.3 years in 2020 because of the COVID-19 pandemic, which is below the average decline of0.7 years recorded across the EU, thus retaining Malta's leading position.

Until early 2021, widespread testing linked to contact tracing, alongside the early introduction of other public health measures contributed to Malta having a tower rate of infection than the EU average.
A strong rise in cases in early 2021 put some pressure on the healthcare system, however, the rapid rollout of the vaccination programme saw over 80% of the population vaccinated by August 2021 and 79% of the population over the age of 18 years had received a booster dose by mid-February 2022- with significant reductions in hospital and ICU admissions and deaths.
Additional public funding was committed to the health sector during 2020 to support the COVID-19 pandemic response, including some aid from the European Union; in particular to invest in and scale up hospital and public health response and health workforce capacity and procure personal protective equipment, diagnostics, treatment and vaccines.

Nonetheless, public funding did not only support the health sector.
The support provided was indeed one of the best historical examples of a whole-of-government and a whole-of-society approach, with allowances and concessions provided to vulnerable persons and their dependent household members, by the Ministries responsible for employment and social security, support for businesses hit by public health restrictions by the Ministries responsible for the Economy and for Tourism, and numerous other initiatives across sectors.
Even businesses and NGOs made several efforts to support the hardest hit.

Malta's National Health Service provides remarkably good access to care to the population, and levels of unmet needs for care are the lowest in the EU.

However, out-of-pocket spending is high, primarily due to private expenditure on primary and outpatient care and on pharmaceuticals prescribed in these settings.

Private health care is often purchased to by-pass waiting lists for certain outpatient services in the public sector.
Long waiting lists are a persistent challenge which was further impacted to some extent due to delayed treatments during the COVID-1 9 pandemic.

That said, the investment in effective public health measures: testing, tracing and isolation, has been crucial in keeping the epidemic largely away from the hospital setting, disrupting elective and preventive health care the least possible.
In fact, catch up efforts targeting surgical operations, screening and out-patient appointment waiting lists have seen public sector waiting list numbers trending downwards.

Digital health Malta accelerated and mainstrearned the use of digital technologies within the health sector during COVID-19 to support communication, surveillance and monitoring, and provision of remote services.

New services and systems included a ,.


Telemedicine Centre, an integrated COVID Test Tracking and Registration System available directly to the public, a digital Passenger Locator Form system, systems to provide Maltese citizens with EU Digital COVID Vaccine.

1§1 and Recovery Certificates), a COVID-19 symptom checker, a national COVID-19 contact tracing app.

a travel and quarantine location authorization system, and new COVID-related functionality in the national my Health patient portal.
Indeed, the deployment rate of health IT tools during 202011 has been unprecedented.

Health care professionals have necessarily made more use of ePrescriptions, IT -based clinical management systems and the new Telemedicine Centre and, with the realisation that more could indeed be done via telemedicine and remote care.

Greater use of digital health technologies and their interoperability is acknowledged as a key strategic action to support efficiency, access and the sustainability of the health sector.
The strengthening of primary and outpatient care has been a health system objective in Malta for the past two decades aimed towards shifting service delivery away from more expensive hospital settings and improving integrated care for chronic conditions.

A new outpatient building at Mater Dei Hospital and two regional primary care hubs are being built, while health centres and community clinics across the country are being modernised.
Reorienting service delivery towards more accessible, cost-effective settings will help further improve health system sustainability.

Mental health A reform of Malta's mental health services has been prioritized over the last few years, in line with the recently published National Mental Health Strategy for Malta, 2020·2030, which places an emphasis on improving quality of care, and shifting mental health care further into the community.
Access to Medicines Ensuring availability of affordable medicines is a critical challenge facing Malta as a small country with limited manufacturing capacity, becoming even more challenging following Brexit.

Increased use of managed entry agreements and clinical protocols for the evaluation of new medicines has contributed to improved availability in recent years.

Initiatives to promote stronger cross-border collaboration, joint procurement and price transparency have successfully enhanced access.
Malta forms part of the European Reference Network (ERN), which is beneficial when it comes to the provision of highly specialized patient care; nonetheless, access to affordable medication that may be prescribed by these centres may present a challenge, that could be addressed in this manner.

Similar approaches could be useful in ensuring access to expensive cancer drugs and medicines for the treatment of rare diseases.
2.3 Health system in Malta Malta's National Health Service (NHS) is predominantly financed through general taxation and provides almost universal coverage to all its resident population.

Emergency care is provided to all, free of charge to all eligible persons including EU citizens, migrants, asylum seekers and for persons coming from countries covered by bilateral health care/ cooperation agreements.
The Ministry for Health is responsible for governance, regulation and financing of the health system, and is the main provider of public health services.

The private sector complements provision of care, particularly for primary care and outpatient services.
Private general practitioners (GPs) account for approximately 70% of primary care visits, with many patients opting to attend private practices where they can choose their physician and set appointments, rather than public clinics, which, in the main, operate on a walk-in basis.

Private and public OPs act as partial gatekeepers to public outpatient hospital services.
However, many people choose to seek outpatient care directly from private specialists without a referral, often to circumvent long waiting lists for certain specialties in the public sector, essentially creating a de facto two-tier health system.

Strengthening primary care and provision of outpatient services has been high on the government reform agenda in recent years.
Health spending in Malta has increased substantially over the last decade Malta has seen the largest real-terms growth rate in total health spending in the EU, and the third highest growth in per capita health spending, behind only Bulgaria and Romania.

Health spending per capita (EUR 2 646) and measured as a share ofGDP (8.8 %} in 2018 nevertheless remained below the EU averages.
Malta's strong economic performance prior to the COVID-19 pandemic has seen rising health spending absorbed by high GOP growth, so that total health spending as a proportion of GOP has declined slightly over the past five years.

The share of public funding for health care in Malta (63.5 %) is low compared to other predominantly tax-funded health systems and is below the EU average of79.7 %.

The low share of public funding is driven by the high proportion of health spending paid out of pocket.
Malta saw a substantial increase in public funding for health during the COVID-19 pandemic, with an additional EUR 130 million initially committed to the health sector during 2020.

Most of this funding was allocated to procuring PPE, critical care beds and other medical equipment, and to increasing the numbers of health workers working directly on COVID-19.
Out-of-pocket (OOP) spending as a share of total health spending in Malta in 2019 was 34.7 o/o- the fourth highest proportion in the EU and more than twice the EU average.

Spending on outpatient care accounted for the largest share ofOOP spending.

This is driven by a substantial proportion of the population opting to purchase private primary and outpatient specialist care services.

OOP spending on pharmaceuticals and LTC was also high.
In 2018, OOP spending on health as a share of final household consumption was 5.5 %, which is about 80% higher than the EU average of3.1 %.

During the last 12 years, Malta has implemented several reforms to address shortages of doctors and nurses, including a series of reforms to improve education, training and employment conditions to help address persistent shortages of health professionals.

These initiatives have contributed to a steady rise in the numbers of doctors and nurses over the past decade.
Malta currently has a higher number of doctors per capita (4.1 per I 000 population) than the EU average (3.9), and the number of nurses per capita (7.9 per 1 000 population) is just below the EU average (8.4) 2.3.1 Universal health coverage All residents in Malta covered by the Social Security Act or a humanitarian exemption are entitled to receive a comprehensive set of publicly provided health services.
Unlike in many EU countries, there are no user fees for public health services: most are provided free at the point of use.

Eligibility for elective dental care, optical services and certain formulary medicines are nevertheless subject to a means test.
All phannaceuticals prescribed for outpatient treatment for most chronic conditions, or during inpatient care in public hospitals and for three days following discharge, are available free of charge to entitled individuals, but other specific medicines and medical devices must be paid for out of-pocket.
In the interest of public health, all COVID-19-related testing (mort: recently apart from tourist travel related testing), screening and care was available free of charge to all individuals, irrespective of residence status or nationality.
2.3.2 Emergency preparedness and response The COVID-19 pandemic has served to highlight strengths and weaknesses in our pandemic plans, including the fact that these plans tended to be more health oriented, and needed to be adapted towards ensuring other services which health also depends on, such as logistics of supply and a better focused whole-of-government approach.
Malta recognises the importance of maintaining and improving health system resilience through continued investment in and consolidation of national emergency preparedness and response, including through training and capacity building.

Malta intends to continue its active participation in regional and global fora, towards ensuring better preparedness and response to future emergencies, including through continued support for the Pandemic Treaty.
2.3.3 Promoting a healthier populatioo In Malta, non-communicable diseases (NCDs) are emerging as a major cause of morbidity and mortality, accounting for 314.7 per I 00, 000 standardised NCO population (20 19).

The most common NCDs include cardiovascular diseases, diabetes mellitus, cancer and chronic diseases.

Malta continues to strive to improve and actively promote the health of its people, towards complete physical, mental and social well-being and not merely the absence of disease or infirmity.
Over the years a lot of investment has gone into and continues to go into the general health infrastructure in a bid to keep pushing and promoting a healthier population.

3.0 WHO AND MALTA: A COLLABORATIVE HISTORY 3.1 WHO's work in Malta Having become a Member State of the United Nations since independence in 1964, Malta joined WHO in 1965 and has been a very active Member State since.
Malta has had a longstanding relationship with the WHO-Regional Office for Europe for decades through successive Biennial Collaborative Agreements (BCAs), previously known as Medium Term Strategic Plans (MTSP).

In 2016, Malta and WHO signed their first Country Collaboration Strategy (CCS) (2016-2022), with the intention to engage in a Jong-tenn and strategic collaboration.

Malta's most recent BCA covered the period 2020-2021.
Throughout the years WHO has technically supported Malta in the development and/or realization of various national health strategies, policies, plans and initiatives.
In more recent years these included the Food and Nutrition Policy Action Plan for Malta (2015- 2020); the National Diabetes Strategy (20 16-2020); National Breastfeeding policy and action plan (20 15-2020); the National Cancer Plan for the Maltese Islands (2017-2021); Communicable Disease Control Strategy for Malta (2013); A Healthy Weight for Life- A national strategy for Malta (2012), the Sexual Health Strategy (2011) and Action Plan, the Mental Health Strategy for Malta (2020-2030), a National Tobacco strategy, a high-level initiative on road safety, and the NHSS- A National Health Systems Strategy for Malta 2014-2020.
A revision of the NHSS, and other strategies are underway following a lull in progress due to the pandemic response.
3.2 Malta's contribution to the regional and global healtb agenda On a technical level, Malta has been involved in many WHO programmes, and actively contributed towards a diversity of documents, resolutions and decisions, developing policies and initiatives that have had long-lasting effects on the approach to health promotion and disease prevention and been at the forefront of global public health.
Malta was a founder member of the Countrywide Integrated Non-Communicable Disease Intervention (CINDI) programme and was also very actively involved in WHO's Expanded Programme on Immunization.

Malta has substantial experience in the various WHO governing body structures.

In the European Region, Malta was a member of the Standing Committee of the Regional Committee (SCRC) in 1993-1995 and 2011-2013 .
The Malta representative chaired the SCRC between September 2013 and September 2014 and was elected Executive President of the 2014 session of the Regional Committee.
During its membership of the SCRC, Malta also chaired the Committee's subgroup on governance and took a leading role in improving transparency in WHO's European governance structures by developing a tool to help select nominees for posts in the governing bodies and elaborating a code of conduct for candidates for election as WHO Regional Director for Europe.
In May 2015, as one of eight member states from the 53 in the WHO European Region, Malta was again elected to the Executive Board (EB), a post which it had not occupied for almost 30 years.

Malta's representative was elected Chainnan of the EB the following year, 2016-2017, and led the selection process for the post of WHO Director General elected by the World Health Assembly in May 2017.
Malta played an active role in the important discussions leading to the development of WHO's Framework for Engagement of Non-State Actors (FENSA), which led to a request by the EB to the Secretariat to prepare an objective and balanced implications paper, in time for Member States to be able to negotiate in full cognizance of the financial and administrative implications of the proposed FENSA text, including at HQ and Regional Office level.
Malta hosted several WHO EURO regional and international meetings related to the various areas of work it has been actively involved in and committed to including in the areas of environment and health, small countries network and road safety.
The WHO 62nd European Regional Committee meeting (RC62), hosted in Malta in September 2012 saw the landmark adoption of the Health2020 European policy framework and strategy, whose development Malta actively contributed towards, as well as supporting the initiative led by WHO EURO.

Following the establishment of the Environment and Health Ministerial Board through the Parma Declaration on Environment and Health in March 2010, the 2010 Regional Committee elected Malta to the Board.
Malta contributed to clearly defining the Board's role through clarification ofits tenns of reference and contributed to starting the process of implementing the Parma Declaration.

Malta worked with the EURO Environment and Health office on two joint publications: a report on Inequalities in Environmental Health in Malta and the Health Impacts of Climate Change in the Maltese Islands publication.
It has continued to be active in the field of environment and health and is also a member of the Transport, Health and Environment Pan-European Programme (THE~PEP) Steering Committee; it was recently elected as a member of the THE-PEP Bureau in 2021.

Malta has been a fronHunner in number of initiatives including the network of small Member States within the European Region- the Small Countries Initiative, and the launching the WHO EURO Health Infonnation Network within the initiative.
The network remained active infonnally through the pandemic with members at technical level consulting each other and sharing expertise and experiences.

The WHO Collaborating Centre at the University of Malta has also kept contributing to WHO and other small states and island communities and intends to continue doing so now that its mandate has been renewed.

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EVOLVING PRIORITIES FOR HEALTH POLICY 4.1 Prioritisation process and alignment with EPW aod GPW Malta's CCS is in line with the European Programme of Work (202~2025) - "United Action for Better Health" (EPW), which aligns the work of the WHO Regional Office for Europe with the triple billion targets of the thirteenth General Programme of Work (GPW 13).

Indeed, these programmes of work provide a solid framework in which to structure Malta's new strategic priorities for the CCS.

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EPW: Th• Aa1lonal Offi~ (ot [urope~ vision on tho'"'"" pnorol<es of tho GPW What do a!llent expect ftom he>lth ••thoritiul 4.1.1 Moving towards Universal Health Coverage Universal health coverage (UHC) can be defined as all people having access to the health services they need, when and where they need them, without financial hardship, and is one of the key priorities of Maltese health policy.
Malta will continue to actively support WHO in the attainment ofUHC at a global level, with work in several related areas.

UHC covers many pressing issues that require global collaboration.

One such example is the challenge of planning, training and keeping a sufficient health workforce capacity; the Covid-19 pandemic has clearly demonstrated that no effective response is possible without sufficient and well-trained health workforce.
• Quality of Care In recent years Malta has collaborated with the WHO European Regional Office through the BCA, in the area of Quality of Care (QoC) and Patient Safety (PS).

Following up on two WHO EURO expert visits and stakeholder meetings at policy and operational level across the health ministry in 2019, and on the recommendations that ensued, Malta would like to further prioritize collaborative work in this area and has been in discussion with the WHO Athens Quality of Care Office.
Following an initial needs assessment meeting with key stakeholders, a program of training is envisaged, together with further discussions towards the drafting of a national patient safety strategy.

• Health Workforce Malta and WHO will continue to collaborate towards the development of an evidenced based sustainable Health Workforce planning mechanism.

In view that currently, data is only partially available and is still fragmented, it needs to be organised, collected in more detail and analysed further.
The result of this baseline needs assessment will fonn the basis for more elaborated short- and long-term Human Resources (HR) planning.

The programme which is currently focused on strategic workforce planning on Primary Health Care but which can be replicated in other Health Care Entities., with the aim of assisting the HR planning cycle for the years 2023-24.

These areas were identified by the Ministry for Health in line with its priority to invest further in Primary Care.
A great amount of progress has been registered within this specific area, where following a visit by the WHO allocated team for Malta a trial has been caried out in the forecasting of HR needs within three specific categories of employees.
In contrast to the current system of HR planning, which is based on a 3-year tenn, this approach is equipping the health ministry's human resources department to move towards a more nuanced, longer-tenn and evidence based planning process, such an exercise will also help the WHO Human Resources for Health Unit to develop forward planning for the workforce rather than the current apportionment system which is based on request and rationing of finance following allocations.
Closer collaboration with the educational institutions for health care professionals is envisaged, with the aim of attracting more applicants to professions where supply is not meeting demand, and to explore possible changes to curricula with the aim of improving skills in specific areas identified by the public health service as the main employer.

• Digital Health The development of digital health services and systems is high on Malta's health service development agenda.
Before COVlD, rapid progress was being achieved to digitalise Government's primary health care centres, to support the introduction of electronic patient records among private family doctors, to establish a National Electronic Health Re<:ords platform, and to build new data and process interfaces between the primary and secondary care sectors, both public and private.

The COVID pandemic focussed attention on digital health, especially telemedicine, remote care, and 'paper-free processes.
The ongoing pandemic has served to further highlight the benefits of having a sound digital health infrastructure, which links sectoral systems together for the exchange of health data.

Telemedicine facilitated the delivery of health care services, for example, mental health and primary care, throughout the pandemic, through teleconsultations and remote patient monitoring.

These ways of working are likely to be retained beyond the pandemic.
The accelerated rollout of digital health services has served to underline the need for digital health literacy among health professionals, and greater digital literacy among patients and the public in general.

Malta is interested in exploring ways in which digital health implementation may complement human resources for health and enable more efficient use of health care worker time towards more effective provision of care.
Malta is also looking at ways of increasing the ability, motivation and opportunity for citizens to access digital health services, not only effectively but also equitably, so that all citizens may be served through digital health services, without anyone being left behind.
Many of Malta's new digital health services involve the sharing of personal health data across the health ecosystem to provide safe, efficient and effective care to patients wherever they need service, while protecting their privacy and confidentiality.

This often involves the building of data and system interfaces between disparate systems.

Malta is interested in best practice examples of successful digital health architectures at national scale.
• Access to medicines Malta has a keen interest in this area and has taken an active role in various for a, including the drafting sessions which led to the milestone transparency resolution on Improving the transparency of markets for medicines, vaccines, and other health products (WHA72/8).

WHO and Malta are collaborating within the framework of the Oslo Medicines Initiative, which Malta strongly supports.
Through the neutral platform established, workstreams to introduce innovative policies and instruments that can improve access to these niche medicines can be tried and tested.

Malta is well placed to support this initiative against a background of priority work resulting in Council Conclusions during Malta's Presidency of the Council of the European ,.
Union on encouraging Member States driven voluntary cooperation between health systems, the work of the Valletta r echnical Committee and the lead role played in the joint procurement of vaccines in the European Union.

4.1.2 Protecting against health emergencies As an active member in EU fora, Malta will continue to contribute towards the development of regional health policy, keeping in mind the importance of maintaining links between WHO and other institutions such as ECDC, HERA and EMA.
At regional and global level, Malta will keep advocating for a stronger and more independent WHO that is able to better guide the world to improved preparedness and response.
Malta will continue to contribute to and support the global recovery from the pandemic, as it has done so far, including through vaccine sharing 4.1.3 Promoting health and weD-being Non-Communicable Diseases Non-communicable diseases are a key area to focus on, with the lowest baseline, minimal anticipated progress and a major contributor to death's and DALY's.

With baselines below the regional median and worsening trends, child and adult obesity requires urgent action.
Acceleration is needed to meet the global tobacco control target: a 30% reduction in tobacco use.

• Mental Health The implementation of Malta's national mental health strategy remains a priority with efforts underway to increase the capacity of the current institutional mental health services which is expected to translate into several initiatives that support assisted living in the community and modernisation of existing wards.
A new Acute Psychiatric Hospital will be built near Mater Dei Hospital in the coming years as an important part of the mental health services reform.

Malta will collaborate with WHO through the pan-European mental health coalition thereby complementing the efforts of the EU MS in the Joint Action on Mental Health.

• Childhood obesity The 2018 Health Behaviour in School Children Study indicated that 44% of I 1-year-old boys and 35% of 13-year-old girls are overweight or obese.
One of the main health related priorities during Malta's Presidency of the Council of the European Union during the first half of 2017, included the important topic of Childhood Obesity.

Discussions resulted in Council Conclusions to contribute towards halting the rise in childhood overweight and obesity being adopted in June 2017.

An intersectoral and whole-of government approach has been the mainstay of Malta's efforts to tackle the public health challenges presented by non-communicable diseases.
The Advisory Council on Healthy Lifestyles, established at law comprises representatives from various ministries besides health, including education and sport, social welfare, local government and home affairs.

The Council actively engages with various stakeholders to tackle specific priority areas The Council is also mandated to make recommendations for new legislation, such as that recently enacted on regulating advertising and food provision in schools.
The envisaged way forward in tackling childhood obesity, particularly following the pandemic, will be through the strengthening ofintersectoral responsibility and collaborative action.
4.1.4 Cross-cutting tbemes ln addition to the focus on the three strategic priorities of the EPW, Malta, in close collaboration with WHO, will use the following three guiding principles in shaping the Maltese and global health architecture and agenda: • Joint Leadership for Health Progress in global health is only achieved when Member States step up and take responsibility.
Malta intends to continue to do so, through its participation in the WHO Governing Bodies and other fora and networks, including the Small Countries Initiative.

It has been evident during the COVID-19 pandemic that small countries have experienced hardship in accessing supplies and vaccines, whilst on the other hand, showing capacity for a nimble and more effective response, thanks to close monitoring of the situation in their territory.
Malta will support the implementation of the Small Countries Initiative roadmap, both by promoting health equity across all aspects, and supporting specific aspects (e.g.

mental health, human resources for health quality of care, long term emergency planning and One Health) as well as providing guidance and advice (e.g.

healthy tourism, health information systems and digital health).
In addition, within the small country initiative a stronger emphasis will be put on equity and the reduction of NCDs and its risk factors, as a follow up ofSC£ commitments.

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• One Health The pandemic has also revealed the necessity of a One Health approach to public health.

The need to increase focus on the relation between health, food, animals, and the environment regarding transmission routes of viruses and bacteria between humans and animals is critical.
The One Health debate needs to be broadened as recent reports state that our world is becoming ever more prone to pandemics due to increased travel and transportation, unsustainable use of natural resources, intensive farming, and climate change.

Hence, we need to pay more attention to these underlying linkages between our globalizing world, climate change and public health.

Malta will continue to advocate for a strong and broader One Health approach.
Malta's political support and presence in the One Health Global Leaders Group has provided an excellent opportunity in this regard.

• Equity The COVID-19 pandemic has once again proven that relentless and transversal attention to equity in health and beyond, remains essential.

Even for high-income countries, attention to equity in all policies should not be considered as superfluous or a luxury.
The most vulnerable have been the most severely impacted both by the pandemic and related mitigation measures, including the poorest, women, those with disabilities, children and young people, frontline workers and people with insecure jobs.

Malta and WHO therefore aim to promote health equity as a value, but also to assure that this value is translated into an operational reality in policies, with health impact assessments as an important tool in this regard.
S. IMPLEMENTING THE CCS The implementation of the CCS will be monitored and discussed during a mid-term high level-meeting between Malta and WHO, which will also serve to continue to foster a relationship based on honesty, trust and respect and to allow both parties to quickly develop new initiatives whenever deemed necessary.

The review process will adopt a principle-based approach, assessing the successes and areas for improvement against the principles of cooperation.
The working group will determine the review methods against each of the principles.

The aim of the review will be to ensure that the strategic priorities continue to be aligned with the national health policy context and to assess the outcomes as a result ofCCS implementation.

Another review will take place sometime before the end of the period covered by the CCS.

It will provide an opportunity to reflect on the effectiveness of this CCS before considering development of future strategies.