Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694840390860.pdf (Malta)
IT-TLETTAX-IL LEĠIŻLATURA P.L.

5236 Dokument imqiegħed fuq il-Mejda tal-Kamra tad-Deputati fis-Seduta Numru 352 tas-6 ta’ Lulju 2020 mid-Deputat Prim Ministru u Ministru għas-Saħħa.

___________________________ Raymond Scicluna Skrivan tal-Kamra TRATTATI JEW FTEHIM IFFIRMATI MAL-ORGANIZZAZZJONI DINJIJA TAS- SAĦĦA U/JEW IL-ĠNUS MAGĦQUDA 15746.

L-ONOR.
L-ONOR.

GODFREY FARRUGIA staqsa lill- Deputat Prim Ministru u Ministru għas-Saħħa: Jista' d-Deputat Prim Ministru u Ministru għas-Saħħa jqiegħed fuq il-Mejda tal- Kamra kopji tat-trattati jew ftehim oħra li ffirmat Malta mal-Organizzazzjoni Dinjija tas-Saħħa (WHO) u/jew il-Ġnus Magħquda li għandhom x'jaqsmu ma' policies, linji gwida u struzzjonijiet konessi mas-saħħa?
Jista' jikkonferma jekk Malta ffirmatx xi trattat jew trattati, jew ftehim ieħor mal-WHO jew ma’ xi aġenzija barranija oħra li tirrigwarda l-maniġġar ta' saħħa f'każ ta' pandemija, u jqiegħed fuq il-Mejda tal-Kamra kopja ta' kull ftehim iffirmat?

30/06/2020 ONOR.

CHRIS FEARNE: Ninforma lill-Onorevoli Interpellant illi qed inpoġġi fuq il-mejda tal-kamra kopja tal-ftehim ffirmat bejn Malta u l-Organizzazzjoni Dinjija tas-Saħħa (WHO- Malta Biennial Collaborative Agreement 2020-2021) għall-perjodu 2020/2021.
Dan il-ftehim gie ffirmat fil-qafas tal-istrategija ta’ kooperazzjoni (CCS 2016-2021) li ffirmat Malta mal- Organizzazzjoni Dinjija tas-Saħħa fl-2016., liema kopja ukoll qed titpoġġa fuq il-mejda tal- kamra.

Tul il-Pandemija, Malta kompliet issaħħaħ il-kollaborazzjoni tajba li għandha mal- Organizzazzjonijiet u Istituzzjonijiet Internazzjonali u Ewropej inklu¿ l- ECDC (European Centre for Disease Prevention and Control) u l-Organizzazzjoni Dinjija tas-Saħħa (WHO).
Seduta 352 06/07/2020 {8\ World Health ~ il Organization ._, ~ REGioNAL oFACE FOR Europe Biennial Collaborative Agreement between the Ministry for Health of Malta and the Regional Office for Europe of the World Health Organization 2020/2021 Signed by: !

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/9 Date Title Deputy Prime Minister and Minister for Health Name Hon Chris Fearne For the WHO Regional Office for Europe Name Dr Zsuzsanna Jakab Title Regional Director Table of contents INTRODUCTION ......................................................................................................................... 2 TERMS OF COLLABORA.TION ............................................................................................... 4 PART 1.

PRIORITIZED GPW 13 OUTCOMES FOR COLLABORA.
TION IN 2020-2021 ......................................................................................................................................................... 5 1.1 Health situation analysis .................................................................................................................... 5 1.2 Agreed areas for collaboration through GPW 13 prioritized outcomes ....................................... 6 GPW 13 prioritized outcomes and links to Health 2020 and the 2030 Agenda in Malta .......................... 6 Linkage of the BCA with national and international strategic frameworks for Malta ............................... 6 Programmatic priorities for collaboration ................................................................. ................................. 7 1.2.1 1.2.2 1.2.3 PART 2.
BUDGET AND COMMITMENTS FOR 2020-2021 ................................................. 8 2.1 Budget and financing ......................................................................................................................... 8 2.2 Commitments ...................................................................................................................................... 8 Commitments of the WHO Secretariat.. ....... ............................................................................................. 8 Commitments of the Government ............... ......................... ... .................................................................. 8 2.2.1 2.2.2 LIST OF ABBREVIATIONS ...................................................................................................... 9 ANNEX 1: GPW 13 RESULTS FRA.MEWORK ....................•............................................... 10 ANNEX 2 ..................................................................................................................................... 11 1 Introduction This document constitutes the Biennial Collaborative Agreement (BCA) between the World Health Organization (WHO) Regional Office for Europe and the Ministry of Health ofMinistry for Health of Malta on behalf of its Government, for the biennium 2020-2021. WHO's Thirteenth General Programme ofWork, 2019-2023 (GPW 13), provides a high-level strategic vision for the work of WHO and provides an overall direction for the five-year period beginning in January 2019. WHO's Programme budget 2020-2021, as approved by the Seventy-second World Health Assembly, aims to tum the bold vision of GPW 13 into reality by delivering impact for people at the country level.
It is the first programme budget developed under GPW 13 and a vital element for ensuring implementation of the strategy set forth in GPW 13.1ts results framework (see Annex 1) demonstrates how its inputs and outputs translate into and are crucial for achieving the triple billion targets ofGPW 13 and for maximizing impact on people's lives at the country level.
The operationalization of GPW 13 begins with the prioritization with Member States of its nine technical outcomes and the cross-cutting outcome on data and innovation for the duration of GPW 13, thus providing a medium-term strategic planning horizon agreed between WHO and Member States.

The 2020-2021 BCAs are then planned, taking this GPW 13 outcome prioritization as the point of departure.
The BCA, grounded in GPW 13 and the 2030 Agenda for Sustainable Development, delivers on the concepts, principles and values underpinning Health 2020, the European policy framework for health and well-being, which was adopted by the WHO Regional Committee for Europe at its 62nd session.
The BCA thus aims to support Malta in maximizing the opportunities for promoting population health and reducing health inequities, by taking an intersectoral, health-in-all-policies approach - involving the whole of society and the whole of government - which emphasizes the need to improve overall governance for health.

The BCA proposes ways of achieving more equitable, sustainable and accountable health development, in line with Health 2020.
Description of the Biennial Collaborative Agreement This document constitutes a practical framework for collaboration.

It has been drawn up in a process of successive consultations between national health authorities and the Secretariat of the WHO Regional Office for Europe.

The collaboration programme for 2020-2021 has started with the bottom-up GPW 13 outcome prioritization process undertaken by the country in cooperation with the Regional Office the country.
This work was carried out as part of WHO's transformation in the overall context provided by GPW 13.

The objective of the bottom-up planning exercise was to determine the priority health outcomes for WHO collaboration with the country during the period 2019-2023.

This document further details the collaboration programme, including the prioritized outcomes, proposed outputs, and product and services deliverables.
2 The outcomes are the desired changes in the Member State's capacities that result in increased access to services and that ultimately contribute to sustainable changes in the health of populations.

These changes in the health of populations are those that the Member State aims to achieve on the basis of its uptake of the WHO SecJetariat's outputs, and hence they are a joint responsibility of the Member State and the Secretariat.
Achieving the prioritized outcomes as identified in this BCA is therefore the responsibility of both the WHO Secretariat and the Government of Malta.

Different modes of delivery are foreseen in the implementation of this BCA, ranging from country-specific (for outputs that are highly specific to the needs and circumstances of individual countries), to intercountry (addressing countries' common needs using Region-wide approaches) and multicountry (for subregional needs).
3 Terms of collaboration The agreed priorities provide a framework for collabpration for 2020-2021.

The collaborative programme may be revised or adjusted during the biennium by mutual agreement, where prevailing circumstances indicate a need for change.
The biennial programme budget outputs for 2020-2021 may be amended by mutual agreement in writing between the WHO Regional Office for Europe and the Government as a result of, for example, changes in the country's health situation, changes in the country's capacity to implement the agreed activities, specific needs emerging during the biennium, changes in the Regional Office's capacity to provide the agreed outputs, or in the light of changes in funding.

Either party may initiate amendments.


After the BCA is signed, the Ministry of Health will reconfirm/nominate a WHO national counterpart and national technical focal points.

The national counterpart will be responsible for the overall implementation of the BCA on the part of the Ministry and will liaise with all national technical focal points on a regular basis.
The Strategic Desk Officer in the Strategic Relations with Countries (SRC) unit of Regional Directors office in Copenhagen will be responsible for implementation of the BCA on behalf of WHO in close coordination with and overseen by the Regional Office, and will coordinate any required support from WHO headquarters.

The BCA workplan, including the planned programme budget outputs, products and services and implementation schedule, will be agreed on accordingly.
Implementation will start at the beginning ofthe biennium 2020-2021.

The WHO budget allocation for the biennium indicates the estimated costs of delivering the planned work, predominantly at the country level.

Funding will come from both WHO corporate resources and any other resources mobilized through WHO.

These funds should not be used to subsidize or fill financing gaps in the health sector, to supplement salaries or to purchase supplies.
Purchases of supplies and donations as part of crisis response operations or as part of demonstration projects will continue to be funded through additional mechanisms, in line with WHO rules and regulations.
The value of the contributions by WHO technical and management staff based in WHO headquarters, the Regional Office and in geographically dispersed offices (GDOs), and by the the Strategic Relations with Countries team and the staff of their respective offices, to the delivery of planned outputs and deliverables, are not reflected in the indicated budget.

This support goes beyond the indicated budget and includes technical assistance and other inputs from WHO headquarters, the Regional Office and GDOs.
The budget and eventual funding included in this Agreement are the Organization's funds allocated for Regional Office cooperation within the country workplan.

The value of the Government's input, other than that channelled through the WHO Secretariat, is also not included in the BCA and the indicated budget.
It should also be noted that this BCA is open to further development and contributions from other sources, in order to supplement the existing programme or to introduce activities that have not been included at this stage.

4 PART 1.

Prioritized GPW 13 outcomes for collaboration in 2020-2021 1.1 Health situation analysis According to the National Statistics Office (NSO) figures, life expectancy at birth in 2018 was 80.5years 78.lyears for men and 83 years for women.
World Bank data for 2016 shows that the probability of dying in the younger age groups (15-60) has been decreasing steadily with a wide gap between males and females.

This is partly attributable to ischaemic heart disease and external causes of death, such as traffic accidents and suicides.

The total crude death rate in 2017 was 8 per 1 ,000 population.

Noncommunicable diseases (NCDs) are a major challenge.

Despite health gains, there are increased risk factors associated with NCDs.
One preventable contributing factor is obesity, which is increasingly prevalent among both adults and children.

Diseases of the circulatory system are the leading cause of death, accounting for 38% of all deaths in 2016, according to the WHO - Noncommunicable diseases (NCD) Country Profiles,2018.

Despite a generally downward trend, ischaemic heart disease mortality rates are higher than the EU 15 average.
Diabetes mellitus as an underlying cause of death accounts for 4% of all deaths, which is also higher than the EU 15 average.

Neoplasms are the second major cause of deaths, accounting for 27% of all deaths, while the rest of deaths are largely attributable to other causes ( 15% ).

diseases ofthe respiratory system (6 %) and external causes of morbidity and mortality (3 %), according to the 2013 Annual Mortality Report.
As the population survives to older age, deaths due to dementia become more important.

Dementia accounted for 4.2% of all deaths in 2015 ( DHIR, 2015).

Mental illness is the leading cause of disability effecting the individuals, families and communities and also has a significant impact on the economy.

OECD estimates that the direct and indirect costs amount to 4% of the national GDP, which in monetary terms for Malta in 2017 is estimated to be in excess of 400 million Euro annually.
Self-harm and suicide are related to mental health disorders.

In 2014, 4.2% of deaths in Malta were attributed to mental and behavioural disorders (EU average 3.

7%) with dementia being the most common cause.

The death rate for intentional self-harm, (suicides) was 8.3% per 100,000 (EU average 11.3) with men being almost seven times more likely to die from intentional self-harm than women.
Deaths from intentional self-harm in over 65 years occurs solely in men and such deaths are 1.5 times more common in this age group than in persons under 65 years Road traffic injuries are the leading killer among children and young people aged 5-29.The total number of road traffic fatalities during 20 18 amounted to 18, one fatality less than those recorded during 2017 (NS0,20 19).
The total number of road traffic crashs that occurred during 2018 amounted to 14,3 78, down by 4.2 per cent when compared to 2017.

Low mortality rates from infectious diseases can be attributed to the widespread availability of antibiotics and antiviral drugs.

The free syringe distribution programme for intravenous drug users, which started in Malta in the late 1980s, has resulted in low rates of HIV infection in this transmission category.
An upward trend in the incidence of HIV in men having sex with men has been observed.

No cases of children infected through mother-to-child transmission have been reported.

HIV infection has been identified as a priority area for action in this field and a strategy is currently being developed.

A free childhood immunization programme for all children has resulted in lower morbidity and mortality from vaccine-preventable infectious diseases.
Substantial work has also been done in the development of emergency response plans for microbial emergencies and pandemic crises.

Capacity building and training in emergency 5 preparedness (in particular Hospital Incident Command Training for Management) will help to consolidate and existing services, particularly in view of the increasing demands on the national emergency and response services.

1.2 Agreed areas for collaboration through GPW 13 prioritized outcomes .
1.2.1 GPW 13 prioritized outcomes and links to Health 2020 and the 2030 Agenda in Malta The following high and medium priorities within frame of GPW13 have been choosen for collaboration: 1.1 - Improved access to quality essential health services; 2.1 - Country health emergency preparedness strengthened; 2.3 - Health emergencies rapidly detected and responded to; 3.1 - Determinants of health addressed leaving no one behind; 3.2 - Reduced risk factors through multi sectoral approaches; 3.3 - Health and well-being realized through Health in all policies and healthy settings interventions.
This BCA for Malta supports the realization of Malta's national health policies and plans.

This BCA has already identified the related key Sustainable Development Goals and supports the realization ofthe and Malta's Country Cooperation Strategy (CCS).
Malta has been an active contributor to the development of the Health 2020 framework document and has supported the initiative being led by the WHO European Office for Investment for Health and Development on addressing the specific issues relating to its implementation in small Member States.

A number of policies, strategies and action plans based on Health 2020 principles have been developed over the past years and are currently being implemented.
Malta has also been active in WHO governance issues at both the global and regional levels.

Addressing social determinants and tackling social inequalities remain one of the priorities for Malta as part of the implementation of Health 2020 and ensuring SDG principle on "leaving no one behind".

The Maltese health system is going through a serie~ of rapid change and development.
Pluralism in the ownership and management of public hospital facilities provides opportunities but also introduces new challenges and requires Maltese authorities to establish the required governance structures to address these new realities.

Close monitoring of the financial sustainability of new initiatives is one such challenge.

The need for stronger intersectoral collaboration is increasingly acknowledged and further support in this regard is still seen as a priority.
Malta will work in partnership to implement the action plan and to promote the strategic objectives of Health 2020 through participation in WHO regional activities as an active member of the Small Countries Initiative, while also promoting the strategic objectives of Health 2020 with national stakeholders.

1.2.2 Linkage of the BCA with national and international strategic frameworks for Malta This BCA for Malta supports the realization of Malta's national health policies and plans.
These include the National Health Systems Strategy (2014-2020), National Cancer Plan (2017- 2021), National Diabetes Strategy (2016-2020), Food and Nutrition Action Plan (2015-2020), 6 Healthy Weight for Life Strategy ( 2012-2020), Sexual Health Strategy (2011) and Action Plan and the Mental Health Strategy for Malta (2020-2030) .

1.2.3 Programmatic priorities for collaboration .


The collaboration programme for 2020-2021, as detailed in Annex 2, is grounded in the above analysis and was mutually agreed on and selected in response to public health concerns and ongoing efforts to improve the health status of the population of Malta.

It seeks to facilitate strategic collaboration and enable WHO to make a unique contribution.
The programme budget outputs and related work on behalf of the WHO Secretariat are subject to further amendments as stipulated in the Terms of Collaboration of the BCA.

7 PART 2.

Budget and commitments for 2020-2021 2.1 Budget and financing The total budget of the Malta BCA is US$ 55000.

All sources of funds will be employed to fund this budget as funds are mobilized by both parties and become available.
In accordance with World Health Assembly resolution WHA 72.1, the Director-General will make known the distribution of available funding, after which the Regional Director can consider the Regional Office's allocations to the BCAs.

The WHO Secretariat will report on its annual and biennial programme budget implementation to the Regional Committee.

2.2 Commitments The Government and the WHO Secretariat jointly commit to working together to mobilize the funds required to deliver this BCA.
2.2.1 Commitments of the WHO Secretariat WHO agrees to provide, subject to the availability of funds and its rules and regulations, the outputs and deliverables defined in this BCA.

Separate agreements will be concluded for any local cost subsidy or direct financial cooperation inputs at the time of execution.
2.2.2 Commitments of the Government The Government shall engage in the required policy and strategy formulation and implementation processes, and when possible provide workspace, personnel, materials, supplies, equipment and local expenses necessary for the achievement of the outcomes identified in the BCA.
8 LIST OF ABBREVIATIONS General abbreviations BCA - biennial collaborative agreement CCS - country cooperation strategy DHIR- Department of Health Information and Research EU - European Union GDO - geographically dispersed office GDP - gross domestic product GPW 13 - WHO Thirteenth General Programme ofWork, 2019-2023 NSO- National Statistics Office OECD - the Organisation for Economic Co-operation and Development SDG - Sustainable Development Goals SRC - Strategic Relations with Countries WHO -World Health Organization Technical abbreviations HIV - human immunodeficiency virus NCDs- Noncommunicable diseases 9 WHO constitutional objective The attainment by all peoples ol the hlpest possible level of health .....
Measurement • Healthy life expectancy (HAlf) ¢ more people benefiting from universal health c:overaae .... OutiClome 1.11mproved M:CMS to quality essential hulth...W.S ....

Outcome 2.1 Countries PNI*Wd for helllh ...,.endes 4.
More effective and effidem WHO provldins better support to countries • • Unlverul health aMMI'll-lndex • Bealer pnMiected Index Outcome 3.1 o.tennlnants ol healtiiMdressed Outcome 4.1 Stnt~lllhened country - - - In claal and lnnovatlcwl • Healthier popullrdons Index Outcome 1.21educed number of people sutleri• ftnanc:MIMrdshlps Outcome Ulrnpnwed aaea to essential medldnes, VIICdnes, dlqnostk:s .... devices for primary halth C3l'l!
Outcome 2.2 Epidemics and ,.ndernlcs prwented Outcome 3.2 Risk t.don reduced thrauP rnuldlectonlllldlon Outcome 1.3 HHith ...... endes ,.plcly deteded n responded to Outcome 3.3 Hulthy settlnp and Health In All Pullcles PfOI'IICMed Outcome 4.1 Stretllthened luclershlp, pem~~nce and .._.,for health Outcome u F1nlndal.

human and admlrdltaallw resouras IMftllll!dln an efllclent.
el'fecllw, results- oriented and transpM!IIt manner • ' Outcome Indicators SDG Indicators + • Bother Indicators J¢ A. Soutputs --i 3 output& ---f 5 outputs I I I 3 outputs 4 outputs 3 outputs J I I 2 outputs -1 2 outputs ---1 2 outouts I I I 3 outputs 6outputs ~ 4aurnuu I I I I Output measurement • Balanced scorecard to be applied at each or the levels of the Orsanfzatfon • Qualitative case studies > 2 2 ~ ~ .... C1 ~ ~ .... ~ ~ ~ \J1 ~ C3 \J1 ~ ~ ~ ~ ~ 0 ~ ~ "' .... f \!)
I j 0 ANNEX2 Biennial Collaborative Agreement (BCA) - Malta Strategic Priority I Outcome Output Description of Products or Services -- SP1.
One Billion More People Benefiting from Universal Health Coverage --·-~~- - - 1.1 Improved access to quality essential health services 1.1.1 Countries enabled to provide high-quality, people -centred health services, based on primary health care strategies and comprehensive essential service packages Support with development of a National Patient Safety Strategy 1.1.4 Countries' health governance capacity strengthened for improved transparency, accountability, responsiveness and empowerment of communities Health system strengthening support to the implementation of the national mental health strategy SP2.
One Billion More People Better Protected from Health Emergencies 2.1 Countries prepared for health eme~g~!
'~!es _ 2.1.2 Capacities for emergency preparedness strengthened in all countries Mass casualty incident management training and Emergency Risk Communication training -~- 2.3 Health emergencies rapidly detected and responded to 2.3.3 Essential health services and systems maintained and strengthened in fragile, conflict and vulnerable settings Strengthening national resilience to reduce health risks and respond to emergencies, including Emergency Care System, and access to essential services SP3.
One Billion More People Enjoying Better Health and Well-Being 3.1 Determinants of health addressed Support to implementation of health deliverables under the national road safety strategy 2014-2024 social determinants of health across the life course • • I ...

I • I .. ... ...
I I 3.2 Risk factors reduced through multisectoral action 3.2.1 Countries enabled to develop and implement technical packages to address risk factors thrqugh multisectoral action Assessment and recommendations for the development of a horizontal framework for the prevention of ill health and promotion of well-being 3.2.1 Countries enabled to develop and implement technical packages to address risk factors through multisectoral action Training of health care workers in in the area of non-communicable disease prevention with a particular focus on mental health 3.3 Healthy settings and Health-in-All Policies romoted 3.3.1 Countries enabled to adopt, review and revise laws, regulations and policies to create an enabling environment for healthy cities and Leadership and Governance of Health Systems in Small States 11 villages, housing, schools and workplaces 12 ~ ... , ~ f.~\ World Health ~~~Organization REGIONAl OfllcHoR Europe ~ PARLIAMENTARY SECRETARIAT FOR HEALTH COUNTRY COOPERATION STRATEGY (CCS) MALTA -WHO REGIONAL OFFICE FOR EUROPE 2016-2021 COUNTRY COOPERATION STRATEGY MALTA- WHO REGIONAL OFFICE FOR EUROPE 2016-2021 1 • Keywords HEALTH PRIORITIES NATIONAL HEALTH PRIORITIES STRATEGIC PLANNING TECHNICAL COOPERATION Address requests about publications ofthe WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2 100 Copenhagen 0, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest).
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... 43 3 • 4 Acronyms and Abbreviations BCA ccs EU GDP HIV NCD NSO RIVM WHA WHO Biennial collaborative agreement Country Cooperation Strategy European Union Gross Domestic Product Human Immunodeficiency Virus Noncommunicable Diseases National Statistics Office Netherlands National Institute ofr Public Health and Environment World Health Assembly World Health Organisation 5 6 Executive Summary This Country Cooperation Strategy (CCS) has been jointly elaborated by the World Health Organization (WHO) and the Parliamentary Secretariat for Health within the Ministry for R Energy and Health of Malta.
It is the result of extensive consultations, both internal and external, with relevant stakeholders.

It is based on a number of national strategies within the Health 2020 policy framework and the WHO Twelfth General programme of Works The CCS is expected to be highly beneficial for Malta as it formalizes and improves on the coordination between Parliamentary Secretariat for Health of Malta and the WHO while it clearly highlights the role to be played by Malta in the global health agenda.
Following and extensive analysis of all the policy documents and the consultation and prioritisation process carried out with stakeholders, four strategic priorities were identified.

These strategic priorities emphasize the contribution, scope, and political commitment of WHO and Malta to the national and regional health agendas through a two way process of collaboration.
The four strategic priorities are: • collaborating on promoting the Health 2020 policy framework, including intersectoral action, towards strengthened people-centred health systems; • addressing the increasing burden ofNCDs, in particular obesity and mental health, through intersectoral and life-course approaches; • supporting cross-border collaboration on health with an emphasis on emergency preparedness and response, including refugee and migrant health; and • further promoting the role of Malta in international health and its global and regional contribution.
Within these four strategic priorities are embodied opportunities for developing national capacities and targeting national health needs, priorities and challenges and provide the necessary direction for a systematic and sustainable collaboration through the formulation of BCAs for the next six years.

7 8 Section 1 Introduction The country cooperation strategy (CCS) is a medium-term strategic framework for cooperation between the World Health Organization and a given Member State.
It is regarded as a key instrument for WHO to guide its work in and with a country, in support of the country's national health policy, strategy or plan.

The CCS fosters a mutually beneficial collaboration platform that addresses the Member State's health needs, expectations and capacities, along with the WHO global health priorities, core functions and comparative advantages.
The strategy will outline a shared strategic agenda, which considers both priority areas ofwork as well as functions and ways of working for the next six years.

Until recently, CCSs were formulated only in other regional offices.

The WHO Regional Office for Europe was not party to this procedure until 2011.
Following discussions at the 62nd session of the WHO Regional Committee for Europe, held in Malta, a resolution (1) called for WHO to roll out CCSs in all those countries that expressed a wish to have a more strategic collaboration.

Moreover, as part of the global reforms within WHO, the new CCS framework is now being actively promoted by the Organization as applicable to all Member States in all regions to ensure a bottom-up planning approach.
This CCS is the joint product of the WHO Regional Office for Europe and the Ministry for Energy and Health of the Republic of Malta as a result of extensive consultations, both internal and external, with the relevant stakeholders.
The process provided an opportunity for Malta to evaluate the aims, objectives, targets and priorities of its various active policies, strategies and action plans and to ensure that actions are taken in line with the principles set out in the Health 2020 European policy framework and strategy for the 21st century, adopted by Member States of the European Region in 20 12 (2).
9 This strategic plan is based on the following WHO and national framework documents: • Twelfth General Programme of Work 2014- 2019: not merely the absence of disease, which provides the high-level strategic vision for the work of WHO (3) ; • Health 2020: a European policy framework and strategy for the 21st century (20 13) (2); • Guide for the formulation of the WHO Country Cooperation Strategy (201 4)(4); • A Strategy for the Prevention and Control of Noncommunicable Diseases in Malta 201 0- 2020(5); • A Healthy Weight for Life: A National Strategy for Malta 2012- 2020 (6); • A Food and Nutrition Policy and Action Plan for Malta 2015-2020 (7); and • A National Health Systems Strategy for Malta 2014- 2020 (8).
Malta has had a relationship with the WHO Regional Office for Europe for decades through successive biennial collaborative agreements (BCAs), previously known as medium-term strategic plans.

The two parties are now in the process of jointly drawing up a country cooperation strategy to serve as a common reference for the next six years, on the basis of which the BCA with Malta will continue to be elaborated every two years.
The formulation of a strategic agenda is central to the outcome of this process, as it ensures that the main priorities continue to be addressed through changes of government and ministry officials and that continuity in the programme of technical assistance delivered by the Organization is maintained.
The CCS is expected to be highly beneficial to Malta, since it formalizes and improves coordination between Malta and WHO, both globally and regionally, and clearly highlights and enhances the country's contribution to the global health agenda.

The CCS makes clear linkages to the role of Malta in supporting WHO as a directing and coordinating authority in global health, in particular through the Institute of Diplomatic Studies and as part of the Small Countries Initiative.
It is anticipated that the CCS will also facilitate and support Malta's efforts towards intersectoral collaboration at the national level and the adoption of whole-of-government and whole-of-society approaches to addressing health issues in the country.
The CCS sets out four priority areas for action, which include implementation of the national health systems strategy, aligned to Health 2020, and health systems strengthening and addressing noncommunicable diseases (NCDs), such as obesity and mental health.

10 • 11 Section 2 The health system in Malta 2.1 Socioeconomic profile The Maltese archipelago consists of the islands of Malta, Gozo and Comino.
With an overall area of316 km2 and a population of 425 384, the Republic of Malta, according to the National Statistics Office (NSO) figures for 2013 (9), has the highest population density and the lowest total population of any European Union (EU) member State.

Population growth has slowed from 1.0% per year in 1990 to 0.34% per year in 2013.
While the crude death rate has been relatively stable over the past 20 years (7 .6 per 1000 persons in 2013 ), there has been a decline in the fertility rate from 2 births per woman in 1991 to 1.53 in 2012.

Malta has an ageing population with an average age of 40.5 years in 2011 compared to 38.5 years in 2005.
According to the same NSO figures for 2013, persons aged 65 and over represent 17.9% of the total population compared to 13.7% in 2005, while persons' aged 14 and under comprise 14.3% ofthe population compared to 17.2% in 2005.

Malta's economy, although small, is diversified and exposed to international market forces.

The economy is dependent on manufacturing, tourism and key service sectors, including financial, business, information technology and remote gaming.
According to the Central Bank of Malta Quarterly Review 2014 (10), the real gross domestic product (GOP) was expected to grow by 2.3% in 2014 and by 2.6% in 2015.

Unemployment is projected to remain low and stable at 6.4% in both 2014 and 2015.

In 2013, the deficit-to-GOP ratio stood at 2.8% and was expected to decrease to 2.7% for 2014 and 2015.

12 2.2 Health status According to the NSO figures for 2013 (9), life expectancy at birth in 2011 was 81.9 years, 79.6 years for men and 84.0 years for women.
World Bank data for 2013 shows that the probability of dying in the younger age groups ( 15- 60) has been decreasing steadily with a wide gap between males and females.

This is partly attributable to ischaemic heart disease and external causes of death, such as traffic accidents and suicides.

WHO European Health for All database(11) reports the total crude death rate in 2011 at 7.86, 8.04 for men and 7.68 for women.

NCDs are a major issue.


Despite health gains, there are increased risk factors associated with NCDs.

One preventable contributing factor is obesity, which is increasingly prevalent among both adults and children.

Diseases of the circulatory system are the leading cause of death, accounting for 40.1% of all deaths in 2013, according to the Maltese Department of Health Information and Research Annual Mortality Report for 2013(12).
Despite a generally downward trend, ischaemic heart disease mortality rates are higher than the EU15 average.

Diabetes mellitus as an underlying cause of death accounts for 3.2% of all deaths, which is also higher than the EU15 average.
Neoplasms are the second major cause of deaths, accounting for 27% of all deaths, while the rest of deaths are largely attributable to other causes (15.8%), diseases ofthe respiratory system (10.6%) and external causes ofmorbidity and mortality (3.3%), according to the 2013 Annual Mortality Report(12).

Low mortality rates from infectious diseases can be attributed to the widespread availability of antibiotics and antiviral drugs.
The free syringe distribution programme for intravenous drug users, which started in Malta in the late 1980s, has resulted in low rates of HIV infection in this transmission category.

An upward trend in the incidence ofHIV in men having sex with men has been observed.

No cases of children infected through mother-to-child transmission have been reported.

HIV infection has been identified as a priority area for action in this field and a strategy is currently being developed.
A free childhood immunization programme for all children has resulted in lower morbidity and mortality from vaccine-preventable infectious diseases.

Substantial work has also been done in the development of emergency response plans for microbial emergencies and pandemic crises.
13 2.3 Organization and governance The Ministry for Energy and Health is responsible for the provision of health services, health services regulation and standards, environmental health, health and safety, and health promotion and disease prevention.

The Ministry for the Family and Social Solidarity is responsible for social policy and policy relating to the child, the family and persons with disability, elderly people and community care, social housing, social security, pensions and solidarity services.
The Ministry for Finance is generally responsible for Malta' s economic policy, preparing the government budget as it collects and allocates taxes and revenue.

Other actors include other government ministries, the Foundation for Medical Services, government commissions, agencies, boards and committees, professional regulatory bodies and professional groups, private and voluntary sectors, the Church and the general public.

The publicly funded health-care system is the key provider of health services.
The private sector complements the provision ofhealth services, in particular in the area of primary health care.

In addition, some services (especially for long-term and chronic care) are also provided by the private sector, religious bodies and other voluntary organizations.
Strategic policy documents with a strong focus on health promotion and primary prevention published by the Ministry responsible for health over the past five years include A Strategy for the Prevention and Control of Noncommunicable Disease in Malta (2010) (5), The National Cancer Plan 2011- 2015(13), the National Sexual Health Strategy 2011(14), A Healthy Weight for Life: A National Strategy for Malta 2012-2020 (6), and the Food and Nutrition Policy and Action Plan (2015- 2020) (7).
In addition, A Whole School Approach to a Healthy Lifestyle: Healthy Eating and Physical Activity (15) is currently being implemented in schools.

These strategy documents are all in line with the principles expounded in the WHO Health 2020 policy framework and strategy document.

There is an urgent need to review and update the national mental health strategy, which is now at least 15 years old.
14 2.4 Financing In 2012, total health expenditure as a percentage ofGDP was 8.7%, of which 3% was private spending.

According to the World Health Statistics 2015 ( 16), state health expenditure represented 13.3% oftotal government expenditure.

The publicly financed health system provides a comprehensive basket of health services to all persons residing in Malta who are covered by Maltese social security legislation.
However, entitlement to a few services (including elective dental care, optical services and some formulary medicines) are means tested.

Accordingly, persons who fall within the low-income bracket as determined by the means test are entitled to free medicines from a restricted list of essential medicines and to certain medical devices (subject to certain conditions and the payment of a refundable deposit).
Furthermore, persons who suffer from chronic illnesses included in a specific schedule incorporated in the Social Security Act (17) are entitled to free medicines strictly related to the chronic illness in question.

This benefit is independent of financial means.

The public system is funded by general tax revenues.

All forms of taxation feed into the Consolidated Fund, from which all public budgets are drawn on an annual basis; the health sector competes with other public sectors for funding .
The main private sources of health financing are out-of-pocket payments and voluntary health insurance.

Out-of-pocket payments account for 93.8% of all private health-care expenditure.

Some external financing has contributed to infrastructure investment, including EU structural funds, with a loan from the Council of Europe Development Bank helping towards the construction of Malta's main acute general hospital, Mater Dei Hospital.
Moreover, the Government is implementing a policy of public-private partnerships to enhance investment in the health sector.

2.5 Physical and human resources There are currently four public hospitals in Malta - the acute general hospital and three others that deal with mental health, oncology and rehabilitation.

There is a further small acute general hospital in Gozo.
The oncology services are in the process of being moved to a new 15 wing within the footprint of the acute general hospital and the current oncology hospital will be closed down.

In addition to the public hospitals, there are four licensed small private hospitals and four private day clinics.

Malta has a bed occupancy rate in acute hospitals (8 1.5% in 201 0) that is above the EU average (75.9% in 2011) (11 ).
The number of acute hospital beds is below the EU average, and has decreased by approximately 28% over the past decade.

The average length of stay in acute hospitals is slightly below the EU average but has been rising.
The number of functioning diagnostic imaging technologies, such as computed tomography scanners and positron emission tomography scans, is among the highest per capita compared to other countries in the Mediterranean region; however, Malta has comparatively few magnetic resonance imaging units.
Particular attention is being given to the use of information technology due to the creation of the Integrated Health Information System and the introduction of new electronic medical records systems alongside the opening of Mater Dei Hospital in 2007.

There are a number of e-health portal facilities to access health-related services.
The latest progress in this area is the introduction of the myHealth service in 20 12, which enables patients and doctors to access electronic health records through a recently implemented electronic identity card system.

The Ministry is currently in the process of drawing up an e-health strategy.

Except in the case of paediatricians, pharmacists and midwives, the number of specialist physicians, dentists and nurses per capita is below the EU average (1 8).
Most medical and surgical specialities have structured training programmes for their trainees, which are supplemented by opportunities to gain further training experience overseas.

Continuing development programmes are ongoing and are widely available to all health professionals.

·In 201 2, there were 349.22 practising physicians per 100 000 population in Malta.

In the same year, there were 708.45 practising nurses per 100 000 population (11).
Both these figures are below the European Health for All targets.

Table 1 shows the number of practising health professionals in Malta for 2012.

16 Table 1.
Number of practising health professionals in 2012 Physicians per I 00 000 Physicians (specialists) per I 00 000 Physicians working in hospitals (percentage) General practitioners per I 00 000 Dentists per I 00 000 Pharmacists per I 00 000 Nurses per I 00 000 Midwives per 100 000 349.22 63.88 57.82 79.86 45.29 116.33 708.45 39.81 Source: WHO Regional Office for Europe, European health for all database 2.6 Provision of services All publicly financed health services are free of charge at the point of use and primary care is readily accessible.
However, the private sector accounts for about two thirds of the workload in primary care; many people choose to pay out of pocket for primary care services in the private sector because it is more convenient and offers better continuity of care.

Secondary and tertiary care is provided through public and private general hospitals, with general practitioners acting as gatekeepers for onward referral to public services.
The main acute general hospital (Mater Dei Hospital) provides the majority of day and emergency care.

In the public sector, medicines on the Government Formulary List are provided free of charge to entitled patients.

In the private sector, patients must pay the full cost of pharmaceuticals.
In the case of highly specialized care for the treatment of rare diseases or specialized interventions, patients are often sent abroad because it would not be cost-effective or feasible to conduct such treatment locally.

The public rehabilitation hospital provides rehabilitation services free of charge to patients referred following inpatient admission at public hospitals or from the community by a general practitioner.

All patients undergo a multidisciplinary assessment.
Long-term care for older people is provided by the Government, the Church and the private sector, as well as through partnerships between the public and the private sectors.

The largest residential home for older people is public.

Increased demand for institutional care has put 17 additional pressure on the public system to adapt to population needs.

Community-based services are being promoted to enable older people to remain at home for as long as possible.
Mental health services are provided from Mount Carmel Hospital, an institutional facility separate from the acute general hospital, which, in addition to most acute mental health services, provides rehabilitation, residential and long-term care services.
Community mental health services are not as developed as expected and attempts at the establishment of outreach, crisis intervention and community support services have not gathered sufficient momentum to realistically facilitate treatment within family and community settings.

Preventive services still need to be developed.

Dental care is provided by public and private providers.
Urgent dental care, as well as diagnostic care, preventive care and oral surgery, is provided free of charge at hospital outpatient departments to all sectors of the community, irrespective of means.

Those who qualify through a means test are also eligible for free restorative care.

In addition, children under 16 years of age enjoy free comprehensive dental care.

Adults pay for most dental care out of pocket.

2.


7 Principal health reforms In the past years, the single event with a major impact on health care was Malta's accession to the EU in 2004.

This was followed by the opening of Mater Dei Hospital in 2007.

Joining the EU was instrumental in driving the long-needed changes in health-related legislation, particularly in the area of public health and pharmaceutical regulation.
The new Mental Health Act, promoting the rights of mental health patients and supporting the move of care to community treatment, was approved in 2012 and came fully into effect in 2014.

A landmark Health Act was also approved by the Maltese Parliament in 2013 (18), repealing the old Department ofHealth (Constitution) Ordinance and establishing a modem framework that separated policy from regulation and operation.

This Act also enshrined patient rights in a legal instrument for the first time.
18 • A number of health reforms have been implemented in recent years.

These include the use of health technology assessment to define the public benefits package, introduction of the Pharmacy of Your Choice scheme to provide more equitable access to medicines, and development of a remuneration system for medical consultants (specialists) that is partially based on performance.

There have also been efforts to develop more community-based services for long-term and mental health care.
2.8 Assessment of health system The Maltese health system provides a comprehensive basket of health services available universally for all its citizens.

According to the European Union Statistics on Income and Living Conditions (dataset) (20), self-reported unmet need due to financial constraints in 2010 was as low as 0.8%, reflecting Malta's major focus on providing equal access to health services for all, particularly for disadvantaged groups.
Indeed, socioeconomic inequalities are more evident among health determinants such as obesity and health literacy than for health care access.

Maltese citizens enjoy one of the highest life expectancies in Europe.

Strategies recently put in place seek to reduce premature deaths, address risk factors and behaviours, decrease morbidity, promote healthy lifestyles and improve quality of life.
A major challenge for the health system is ensuring sustainability as Malta faces increasing demands from its citizens, an ageing population and the rising costs of medicines and technology.

As part of addressing the sustainability of public finances, the focus is on maximizing efficiency in the health system, together with investment in primary and community-based health care.
Systematic monitoring of health systems performance has also become imperative, with WHO currently supporting a health systems performance assessment framework that could potentially serve the purpose of regular monitoring of selected performance indicators.

Waiting times for services are a long-standing challenge that the Government is actively addressing.
19 2.9 Challenges Malta, like other countries, faces important and entrenched challenges that, above all, affect the sustainability of the system owing to constraints in financing.

The impact on the provision of services brought about by a progressively ageing population significantly affects the supply and availability of a number of clinical, pharmaceutical and community services.
The development of new technology and pharmaceuticals contributes to other supply constraints stemming from financial and infrastructural limitations.

The need to proactively address the health problems brought about by NCDs and the respective risk factors is equally challenging, with a substantial need for additional human and financial resources.

Nevertheless, there exists a strong political commitment to ensuring the provision of a high quality health system that is accessible, safe and sustainable.
20 21 Section 3 Development cooperation and partnerships Soon after its independence in 1964, Malta joined the United Nations family on 1 December of that year and was accepted as a member of WHO during the Eighteenth World Health Assembly in 1965.

Malta has since been an active member of the Organization at the technical and governance levels.
It has hosted a number of technical meetings and two Regional Committees, namely, the 20th session of the Regional Committee for Europe in I 970, only five years after Malta became a member of WHO, and the 62nd session 42 years later in 2012.

The latter may be regarded as one of the key Regional Committee meetings, since the Health 2020 policy framework document was adopted during the session.
During its 50 years of membership ofWHO, Malta was a member of the WHO Executive Board from 1986 to 1988 and was elected for another three-year period starting in May 2015.

Malta was a member of the Standing Committee of the Regional Committee for Europe from 1993 to 1995 and from 2011 to 2013, and its representative chaired the Twenty-first Standing Committee between September 2013 and September 2014.
Apart from representation on these two governing bodies, Malta was a member of the European Environment and Health Ministerial Board between 2010 and 2013.

Malta has also engaged with a number of partners in the field of health at both the governmental and non-governmental levels.

It has been a member of the Council of Europe since 1965 and has continuously contributed to the execution ofthe Council's values and principles in the area of promoting and safeguarding public health.
It is scheduled to take over the Council of Europe presidency in 2017.

At the same time, Malta will hold the rotating presidency of the Council of the European Union, during which it will focus on the issue of overweight and obesity as its primary health theme - a public health problem that affects most European countries.

It will also address issues related to the accessibility and affordability of health care through structured cooperation.
In the context of its EU Council 22 presidency, Malta will host a number of high-level meetings, conferences and workshops relating to various public health issues.

Since independence, Malta has remained a member of the Commonwealth ofNations and has always actively participated in meetings of the organization's health ministers.

Over the past four years, Malta has been a member of the Commonwealth Advisory Committee on Health and Chair from 2014 to 201 5.
During its membership and chairmanship, Malta steered a number of governance reforms and contributed to the preparation of the programme of work for the Commonwealth health section, which focused primarily on universal health coverage, NCDs and e-health.

In addition to its relations with WHO, Malta also has a number of bilateral cooperation agreements with other EU and non-EU member States, such as Italy, the United Kingdom, China, Israel and Qatar.
Such bilateral agreements provide for technical cooperation between the two countries, clinical support, and training, as well as exchange of expertise in the field of health.

Malta has also provided critical support in the field of health during the crises in Libya and Tunisia in 2012.

It served as the transit point for 21 000 foreign workers and expatriates, who fled Libya to return to their homeland.
The massive influx of people into a small country with a very limited resource capacity was a major challenge that Malta managed to overcome.

In addition, the country also provided, within its resource limitations, acute hospital care to civilians who were wounded as a result of the fighting and served as a shipping base for medical supplies to be sent to the most affected areas.
During this time, there was significant coordination among the various entities locally and collaboration with United Nations agencies and other Member States, as well as voluntary nongovernmental organizations.

Because of its geographical position between Africa and Europe, Malta receives a number of refugees and migrants departing by boat from the north African coast.
In view of possible large influxes of refugees and migrants, surge capacity is limited due to the size ofthe island and the relative impact on the health system.

23 Section 4 Past and current cooperation with WHO Malta has had structured cooperation arrangements with WHO for many years, even before the introduction of BCAs in the early 1990s.
Through the various BCAs signed over the years it has received a significant amount of technical assistance, which helped it to develop, implement, monitor and evaluate its many policies, strategies and action plans.

This section will concentrate on the priority areas that have fonned the basis of the four most recent BCAs, since it is not possible to go through all the areas that have been covered over the years.
The priority areas for collaboration with WHO since 2008 were selected in response to the public health concerns at the time and the ongoing national efforts to improve the performance of the health system.
Such areas include: • • addressing policy development for health promotion and disease prevention; strengthening national environment and health; • health systems strengthening; and • increasing capacity for policies that address social determinants of health in order to enhance and integrate pro-poor, gender responsive and human rights-based approaches.
The agreed medium-term priorities mentioned above were taken as a starting point, while the new vision of the WHO Regional Office for Europe, Better Health for Europe (21), endorsed at the 60th session of the Regional Committee for Europe, as well as the concepts, principles and values underpinning the development of a country strategy for the Regional Office (1) and the European policy framework for health and well-being, Health 2020 (2), was taken into account.
Although the main areas for collaboration were retained, the emphasis on each area changed according to the perceived need of the country.

24 4.1 Policy development for health promotion and disease prevention The fact that Malta needed to develop a strategy for addressing the problem ofNCDs was immediately recognized.
NCDs such as cardiovascular diseases, cancer, chronic obstructive airways disease and mental ill health are a significant health and economic burden on the country and therefore require an effective strategy to address them.

Following consultation with internal and external stakeholders, it was decided to approach the problem by addressing specific NCO areas, as well as a number of key risk factors.
The drafting of the document was inspired primarily by the vision of the WHO countrywide integrated NCO intervention programme and the guiding principles underpinning the Health 2020 framework policy document, which was still being drawn up at the time.
Following an in-depth review by the respective technical division at the Regional Office, the document A Strategy for the Prevention and Control of Noncommunicable Diseases in Malta 2010- 2020 (5) was launched by the Minister for Health and the WHO Regional Director in Valletta in April2010.

With the launch of the NCO strategy, it became evident that a number of other strategies were required in order to address NCOs and their risk factors.
Priority was given to the development of a strategy to tackle the issue of obesity.

Malta faces a growing obesity problem, with approximately 50% of children and 60% of adults being overweight or obese, which has become a source of increased public health concern.
The Regional Office was involved from the very early stages of the development ofthis strategy, undertaken in collaboration with a number of other stakeholders through the Intersectoral Committee to Counteract Obesity, and the drafting of the document was also done intersectorally .

A number of seminars and consultation meetings took place in Malta, some coordinated by WHO technical experts from the Regional Office, which thoroughly reviewed the final document.
In February 2012, the Minister ofHealth launched the document A Healthy Weight for Life: A National Strategy for Malta 2014- 2020 (6) and invited the regional Programme Manager for Nutrition, Physical Activity and Obesity to attend the event.

The next policy to be developed addressed food and nutrition.

In the 1980s, Malta was the first country in the European Region to adopt a national food and nutrition policy, but which had never been reviewed.
Like the obesity strategy, the Regional Office was again involved from the beginning in developing a new document, together with a number of stakeholders, 25 including technical experts from the Regional Office and WHO headquarters.

Assisted by such experts, the Analysis Grid for Environments Linked to Obesity process, a tool developed by WHO, was used to identify the priority action areas that should be addressed and the relevant action plans to be drawn up.
In December 2014, the Parliamentary Secretary for Health and the Regional Director for Europe launched the document A Food and Nutrition Policy and Action Plan for Malta 2015- 2020.

(7) The lack of local data, in particular in the area of food consumption patterns by the population, was one of the issues identified during the development of the strategies mentioned above and the drafting of their respective implementation plans.
It was therefore decided that a scientifically sound national food consumption survey was required.

This would not only provide a baseline status but also help to identify and quantify the scale of the major nutrition-related problems and would serve as a useful tool for monitoring progress and developing relevant policies.
Through the intervention and support of the Regional Office, Malta entered into a collaborative agreement with the Netherlands National Institute for Public Health and the Environment (RIVM), a WHO collaborating centre.

Through this agreement, the RIVM has assisted the Directorate for Health Promotion and Disease Prevention in formulating and developing the necessary tools to ensure the collection of accurate food consumption data, comparable to similar data for other European countries.
The pilot phase has been completed, and the national survey is due to start in September 2015.

Another policy that has been developed with the help and support of the WHO Regional Office for Europe relates to breastfeeding.

Once again, Malta had a national breastfeeding policy dating back to the year 2000 that had never been reviewed or updated.
After extensive consultation with a wide spectrum of stakeholders, adopting a whole-of-government/whole of-society approach in line with the Health 2020 principles, the National Breastfeeding Policy and Action Plan 2015-2020 was finalized.

Following review by and input from the Regional Office, the document was approved by Cabinet.

WHO also provided assistance and support in drawing up the policy for A Whole School Approach to a Healthy Lifestyle: Healthy Eating and Physical Activity.
(15) With the adoption of the Vienna Declaration on Nutrition and Noncommunicable Diseases in the Context of Health 2020, (22) approved by ministers in July 2013 and endorsed at the 63rd session of the Regional Committee for Europe, and in line with the development ofthe 26 Physical Activity Strategy for the WHO European Region 2016- 2025 (23), Malta embarked on the drafting of a national strategy on health-enhancing physical activity.
After meetings with the Regional Office and through WHO technical expert support to undertake a consultation process with relevant stakeholders, the strategy is at an advanced stage; it is expected that a final draft document will be presented for wide consultation by the end of 2015.
In addition to developing the above-mentioned policies, strategies and action plans and their implementation plans, Malta has been an active member of the Nutrition-friendly Schools Initiative and the WHO European Childhood Obesity Surveillance Initiative and participated in all activities relating to their implementation.

In 2016, Malta will integrate the latter Initiative with the dental health and the national food consumption surveys.
It has also pledged to host the obesity surveillance network meeting during its EU Council presidency in 2017.

4.2 Strengthening national environment and health Malta has been an active participant of the European Environment and Health Process since its inception in 1989 and has actively participated in all subsequent ministerial conferences.

With the help and support of WHO, Malta published its first National Environment and Health Action Plan in 1997.
This gave rise to a number ofintersectoral committees where the Health Ministry played a prominent role, including the Tourism and Health Committee and the Transport, Environment and Health Committee.

It also led to the Ministry of Health holding a permanent seat on the Malta Environment and Planning Authority Board.
In April 2004, Malta hosted the preparatory meeting for the Fourth Ministerial Conference on Environment and Health, held in Budapest, Hungary, after which a second version of the National Environment and Health Action Plan (24) was drawn up; however, this became the Children's Environment and Health Action Plan in 2005.

The national action plan was later revised to cover the period 2006-20 I 0.
In line with the commitment made by ministers at the Fourth Ministerial Conference in 2004, Malta was one of the first countries to work with WHO in carrying out an environment and health performance review, the result of which was published in 2009 .
The review identified the most important environment and health issues, evaluated the public health impact of environmental exposure and reviewed the policy and institutional framework, taking into account the institutional set-up, the policy setting and legal framework, the degree and structural functioning of intersectoral collaboration and the available tools for action .

Malta was also involved in further collaboration with WHO in the area of climate change and health.
Fallowing the National Seminar on Health Effects of Climate Change - Raising Awareness and Building Capacity, organized in Malta in April 2009, further intersectoral work resulted in the joint publication Health Effects of Climate Change in the Maltese Islands, launched in 2010 during a visit to Malta by the Regional Director for Europe.
The document examines the effects on human health of climate change due to increasing temperatures, extreme events, influences on water quality and quantity and ecosystems, and at the influence of weather and climate on overall mortality, food safety and vector-borne diseases.

Impacts particularly highlighted were those of heat and food safety, as well as migration from neighbouring countries.
The publication concludes with a set of recommendations on actions required to protect health in the light of the effects of climate change.

This work was subsequently used by WHO as a case study.
Following the commitment to reduce environmental risks to health by 2020 made at the Fifth Ministerial Conference on Environment and Health, held in Parma, Italy, in 2010, and as part of its response to the implementation of the Health 2020 policy framework, adopted in Valletta in 2012, Malta requested the support of WHO to carry out an assessment of environmental health inequalities.
This assessment was based on a set of 14 core indicators of inequality related to housing, injuries and the environment developed by the WHO Regional Office for Europe with national data providing a good snapshot of the current distribution of environmental risk factors .

The report, entitled Environmetal Health Inequalities in Malta published in 2013 (26), indicated that environmental health inequalities are a reality in Malta.
The findings and measures to be taken to address the issues identified were discussed at an intersectoral meeting coordinated by a technical expert from the WHO European Centre for Environment and Health in Bonn, Germany.
28 4.3 Health systems strengthening Towards the middle of the first decade of this millennium, around the time when Malta became a full member of the European Union, the need to strengthen the health systems performance in the pharmaceutical sector was considered to be the most urgent priority for collaboration with the Organization.

With the help of WHO experts, support was provided for the development and implementation of a National Medicines Policy for Malta.
Particular technical advice was given on the validation and revision of the Government Formulary List, possible alternatives for the procurement of medicines and the evaluation and adjustment of the pricing and reimbursement processes.

Technical expert advice on the setting up of a structure and the development of processes for health technology assessments in relation to new service priorities was also provided.
The adoption ofthe Tallinn Charter: Health Systems for Health and Wealth in 2008 (27) emphasized the need for a strong health system to address the growing health challenges in a context of demographic and epidemiological change, widening socioeconomic disparities, limited resources, technical development and rising expectations.

It is therefore not surprising that the emphasis on the various components of the health system changed.
Consequently, with the support of technical expertise from WHO, Malta embarked on the development of two important projects for health systems strengthening; namely, the drafting of a national health systems strategy, launched in 2014, and the compilation ofthe first health systems performance review with the aim of identifying strengths as well as areas that still required improved efficiency.
In 2013, the Regional Office supported the development of a national strategy for health systems strengthening in line with the principles and values of Health 2020. ln line with Malta's pledge to provide an integrated people-centred health service, it became evident that more awareness-raising within the various responsible sectors was required to ensure that the appropriate policies, human resources and financing were in place to be able to fulfil this commitment.
In this regard, in early 20 I 4 a team of WHO experts visited Malta to coordinate and support a high-level policy dialogue, which was attended by senior government ministers.

A subsequent mission supported quality strategic purchasing in 2015.

29 • All Member States acknowledged the need to strengthen the capacity of health systems in order to implement Health 2020.

However, such capacity-building is of particular significance to smaller countries.
Malta has supported and been an active contributor to the Small Countries Initiative, a platform for small Member States set up by WHO through its European Office for Investment for Health and Development in Venice, Italy.

This platform provides the most appropriate forum for countries with similar challenges to discuss and to share experiences in dealing with particular problems relating to the achievement of the Health 2020 goals.
Malta has pledged to host the meeting of ministers participating in the Small Countries Initiative in 2017.

From 2002 to June 2013, 16 974 refugees and migrants arrived in Malta by sea, reaching a peak of 2775 refugees and migrants arriving in 84 boats in 2008.

Since then, Malta has been strengthening the country capacity to deal with large influxes of refugees and migrants in implementation of World Health Assembly resolution WHA61.17 on the health of migrants adopted in 2008.
To this end, an assessment of Malta's health system capacity to manage large influxes of refugees and migrants was jointly conducted by the country's Ministry for Energy and Health and WHO.
The joint mission took place on 25- 29 November 2013 ; the assessment team consisted of experts from the Ministry of Health, the European Centre for Disease Prevention and Control, the United States Centers for Disease Control and Prevention, the International Centre for Migration, Health and Development, a temporary WHO Migration Health Adviser seconded by the Portuguese Ministry of Health and the WHO Regional Office for Europe.
This provided the basis for the collaboration on preparedness, NCDs and cultural mediation for health in relation to influxes of refugees and migrants in 2014 and 2015.

4.4 Increasing capacity for policies that address social determinants of health While increased capacity for policies to address the social determinants of health has been regarded as a priority for many years, apart from the environmental health initiative discussed earlier, work in this area has not been as active as in other fields.
As highlighted by the EU and the WHO Commission on Social Determinants ofHealth in its final report of2008 30 • entitled "Closing the gap in a generation: health equity through action on the social determinants of health" (28), the conditions in which people grow, learn, live, work and age are major health determinants and therefore policy decisions taken in different sectors will have a collateral impact on other areas, in particular the health sector.
To this end, a workshop was held in collaboration with the WHO European Office for Investment for Health and Development in Venice to cover the various aspects of intersectoral working in a systemic manner.

The workshop helped participants from different sectors to better understand these aspects and enhanced their skills in identifying ways to overcome obstacles to the various challenges of intersectoral working.
Addressing social determinants and tackling social inequalities remain one of the priorities for Malta as part of the implementation of Health 2020.

Ad hoc consultation with WHO was undertaken as the need arose over the years in order to put into practice the various polices, strategies and action plans that have been developed and are now in the implementation phase.
The need for stronger intersectoral collaboration is increasingly acknowledged and further support in this regard is still seen as a priority.

31 • Section 5 Strategic agenda for cooperation Within the context of the CCS development, a strategic agenda for cooperation has been jointly elaborated between Malta and WHO to serve as a framework for biennial operational planning and resource allocation.
Five strategic priorities were determined throughout a prioritization process that took into consideration the objectives of Malta and WHO policy documents, including the European Health 2020 policy framework and the Twelfth General Programme of Work 2015- 2019.
5.1 Prioritization process A multistage prioritization exercise was conducted to define the strategic agenda for cooperation, starting with a national health situation analysis to identify the current health priorities and health development needs of the country.
Next, as part of the strategic formulation process, the Parliamentary Secretariat for Health within the Ministry of Energy and Health convened a stakeholder meeting/focus group to encourage the active involvement of selected national stakeholders in defining the strategic agenda.
The stakeholders included delegates at all levels of the Ministry and also senior officials and directors of other ministries and government departments, scientific institutions, professional associations, foundations and academia and representatives of civil society.

The stakeholder meeting captured the inputs from, and perceptions of, key stakeholders in Malta with regard to a set of proposed strategic priorities for cooperation between Malta and WHO.
The comments were considered and integrated into the CCS, which was reviewed by WHO.

This ensured that the priorities chosen were thematic areas where Malta and WHO had specific expertise and resources that would result in mutually beneficial collaboration at the global, regional and national levels of the Organization.
32 • 5.2 Strategic priorities The following four strategic priorities were mutually identified by WHO and Malta: I. collaborating on promoting the Health 2020 policy framework, including intersectoral action, towards strengthened people-centred health systems; 2. addressing the increasing burden ofNCDs, in particular obesity and mental health, through intersectoral and life-course approaches; 3. supporting cross-border collaboration on health with an emphasis on emergency preparedness and response, including refugee and migrant health; and 4. further promoting the role of Malta in international health and its global and regional contribution.
These high-level medium-term strategic priorities emphasize the contribution, scope and political commitment of WHO and Malta to the national and regional health agendas through a two-way process of collaboration.

A manageable number of strategic priorities have been intentionally chosen to ensure that resources are available over the medium term.

The identified strategic priorities do not capture ongoing routine interactions between the Regional Office and the Ministry for Energy and Health of Malta.
Yet, should the need arise due to other public health emergencies, cooperation between Malta and WHO in further significant areas of global and/or regional health could be envisaged using the CCS collaborative platform.

The Health 2020 policy framework seeks to maximize opportunities for promoting population health and well-being by reducing health inequities and improving governance.
A core direction to achieve these priority objectives is strengthening public health and moving towards a sustainable people-centred health system.
33 Within this strategic priority, the following elements for collaboration have been identified: • • further enhancement and strengthening of quality strategic purchasing; further development of regulatory arrangements, with special emphasis on evaluation of performance and the quality ofthe services provided; and • exploring innovative methods to improve sustainability of the health system and its financing.
WHO will continue to support and facilitate Malta's initiatives with regard to the strategic purchasing of health-care services and commodities.

WHO will also support and facilitate the implementation of measures to ensure that health systems are equipped with quality systems to ensure the highest standard of care for the population.

Such activities should be carried out within a framework that ensures the whole system remains sustainable.
In this regard, WHO will help Malta to explore new mechanisms for health funding and financing within its overall policy of free health care for all.

Malta will work in partnership to implement the action plan and to promote the strategic objectives of Health 2020 through participation in WHO regional activities as an active member of the Small Countries Initiative, while also promoting the strategic objectives ofHealth 2020 with national stakeholders.
WHO is expected to continue providing technical assistance to increase Malta's capacity to improve the level of health by encouraging government authorities, local communities and decision-makers across the public and private sectors to establish mechanisms for whole-of government and whole-of-society approaches to health.
WHO will also continue to support Malta in addressing health inequities faced by refugees and/or migrants in the country and during the process of transit from their country of origin to that of final settlement.

34 • NCDs are the major causes of morbidity and mortality in Malta, as is the case in the rest of the European Region.
In line with the second priority action areas of the Action Plan for Implementation of the European Strategy for the Prevention and Control of Noncommunicable Diseases 2012- 2016 and of the Food and Nutrition Policy and Action Plan for Malta 2015- 2020, which forms part of the overall strategy for the prevention and control ofNCDs in the country, Malta, with the support of WHO, has embarked on a comprehensive national food consumption survey, with fieldwork starting in 2015.
Within this strategic priority, the following elements for collaboration have been identified: • strategic analysis of the results ofthe survey; and • development of policies and/or actions to address recognized dietary and physical activity issues.

WHO will support and facilitate the analysis and implementation of the survey results and will help develop the necessary policies; Malta will work in partnership with WHO to develop a global tool for the measurement of food consumption in Member States.
Obesity is a major risk factor for a number ofNCDs and one of Malta's major health priorities.
Taking into consideration Malta's priority in relation to the problem of obesity in childhood and the WHO European Childhood Obesity Surveillance Initiative, the following elements have been identified in this strategic priority area: • implementation of the whole school approach to a healthy lifestyle; • development of a regulatory mechanism for marketing of foods high in fat, sugar and salt to children; and • development of an intersectoral approach for enhancing physical activity.
35 • Intersectoral approaches are necessary to address health inequities and to deal with the accessibility, affordability and appeal of healthy foods to people of all ages and all incomes.

They are also instrumental in ensuring that physical activity is improved for people of all ages, which requires the further promotion of healthy modes of transport in Malta.
Another key issue is dealing with advertising and the media and its approaches, since consumption of food high in salt, sugars and fats, as well as the very high consumption of sweetened beverages, are considered major contributors to the problem of childhood obesity.

In the case of mental health, Malta will enhance whole-of-government and whole-of-society approaches as part of a new strategic direction to address this national issue.
Key to this is mainstreaming mental health within acute service provision and improving social determinants of health, in particular in the areas of education and employment.

Also, since mental ill health occurs at any age, it requires a life-course approach.

Of particular importance is addressing the needs of children of people with mental health problems, which can prevent the possible onset of mental illness in children with parents or siblings with such problems.
More emphasis will be placed on the issue of mental health and migration (vulnerable populations), as the mental health of refugees and migrants is of concern.

Dementia, as well as mental health issues in people suffering from NCDs, such as cancer, diabetes and alcohol addiction, will also be addressed.
Within this strategic priority, the following elements for collaboration have been identified: • drawing up of an updated mental health strategy and action plan; • development of public mental health services with emphasis on community-supported living, early detection and intervention, and integration of crisis response services; and • elaboration of a national policy or action plan to address alcohol use, followed by relevant regulation.
WHO will support the development of intersectoral action plans to implement the strategies mentioned above and will promote the necessary exchange of information and good practices to help Malta achieve improvements in such issues nationally.

In the case of cancer, WHO will assist in the evaluation of the country's National Cancer Plan 2011- 2015 and advise on how to further improve it.
Exchange of information and good practice in the case of new 36 technologies and their affordability and sustainability will be promoted by WHO at the regional level and through the Small Countries Initiative.

Malta will also strive to recognize and nurture the linkages between natural systems, biodiversity and health and to achieve the maximum health benefits that such systems can provide.
These benefits arise from the availability of ecosystem services and green infrastructure for recreation, exercise and health recovery, leading to a better overall quality of life.

Malta faces the constant threat of a massive influx of refugees and migrants requiring health care.

Moreover, there is a major risk of the cross-border spread of diseases from other countries where disease surveillance and control are not robust.
Within this strategic priority, the following elements for collaboration have been identified: • development of capacity to deal with health needs in the situation of a massive influx of refugees and migrants; and • development of capacity to respond to health threats, including those arising from environmental determinants of health, in particular with regard to extreme weather events, chemical pollution and improving resilience of water supply and sanitation systems.
WHO will support the ongoing development of an ad hoc contingency plan for large influxes of refugees and migrants and its regular update and will also support the development of links with other Member States for the required capacity-building.

WHO is also asked to facilitate the joint procurement of medicines for such situations, in particular the more expensive ones and those used for the treatment of rare diseases.
WHO will also assist with capacity-building for and training in risk assessment and emergency response.

37 Malta will support WHO in helping Member States to develop effective surveillance systems for communicable diseases.

Its presence and leadership role in the Small Countries Initiative provide a unique opportunity for Malta to discuss common issues, such as the joint procurement of medicines, and to share its experiences in addressing refugee and migrant health and other cross-border health issues.
s i Malta has been an active contributor to the development of the Health 2020 framework document and has supported the initiative being led by the WHO European Office for Investment for Health and Development on addressing the specific issues relating to its implementation in small Member States.

A number of policies, strategies and action plans based on Health 2020 principles have been developed over the past years and are currently being implemented.
Malta has also been active in WHO governance issues at both the global and regional levels.

Within this priority area, the following elements for collaboration have been identified: • development of a supporting network for small Member States; and • capacity-building in global and regional health diplomacy.

Malta will share its experiences in the field and play a more active and prominent role in discussions and activities undertaken by the Small Countries Initiative.
Through the national Institute oflslands and Small.States, Malta will promote exchange of good practice, and assist WHO in driving subregional policy and action by taking the lead on a number of issues where national expertise or experience prevails.
The Institute is awaiting recognition as a WHO collaborating centre, which will enable it to contribute directly to the research, evidence and capacity-building that may be required to support the Small Countries Initiative, providing opportunities for Malta's academia to be more internationally connected.

38 Malta wi11 also actively support WHO in its efforts to promote expertise in the field ofhealth diplomacy.
The main emphasis in the first years is to focus on regional health diplomacy for EU member States.

It will seek to organize health diplomacy training on a regular basis from December 2015.

Further outreach to a more interregional or global audience may be explored in the future.
WHO, for its part, will support Malta by working towards awarding it country cooperation status, assisting in national health policy implementation, helping to set up the first health diplomacy course, and strengthening its capacity to plan, discuss, put into practice, monitor and evaluate approaches, initiatives and activities that are not only beneficial nationally but also to other small island countries.
39 Section 6 Implementing the strategic agenda The CCS for Malta will serve to drive the strategic agenda for collaboration between the Ministry for Energy and Health and WHO over the next six years.

Under this agenda, the Ministry for Energy and Health of Malta and WHO will work together to implement the strategy with resources made available by both parties in order to achieve shared goals and to ensure maximum impact.
The health priorities identified will guide the direction of strategic collaboration with WHO from 2016 to 2021.

Since some ofthe strategic areas described entail the involvement of other key stakeholders at various levels, the Ministry for Energy and Health will continue to build on current practices and to further support, promote and coordinate intersectoral approaches at the national level.
This will entail the use of valuable tools, such as the Health 2020 policy framework, in order to foster cooperation and to support action for health and well-being within the country, as well as encourage a more proactive participation and leadership of Malta in global and regional health diplomacy engagement and in the Small Countries Initiative.
Meanwhile, the WHO Regional Office for Europe will foster and harmonize the regional partnership and collaboration with the Ministry for Energy and Health of Malta through the Parliamentary Secretary's office and the WHO national counterpart.

The Regional Office will assist with implementation of the Health 2020 framework, which guides health policy development in the European Region and, through this tool, achievement of the strategic priorities in a more integrated and coherent way.
WHO will promote and advocate Malta's leadership on relevant health topics at the global and regional levels, particularly as a member of the Executive Board, and will continue to support the country's contribution to such health agendas, including through capacity-building and assistance to further develop national health expertise.
40 6.1 First steps The Ministry for Energy and Health of Malta and WHO will promote the CCS to the Government and to the relevant technical departments and units to guide the collaborative programmes and activities.

Successful completion of some strategic priorities is dependent on the involvement, commitment and participation of other ministries and sectors, as only through them and their combined efforts can some targets be successfully reached.
The Ministry will therefore ensure the launch of the CCS among all stakeholders and also its wide dissemination to the Government and other partners working in and with the country on health-related matters.

The WHO Regional Office for Europe and WHO headquarters will also disseminate the CCS document to all WHO departments and divisions to ensure that it serves as a framework for future discussions on country activities.
6.2 Monitoring of the CCS The WHO national counterpart will issue a call for certain stakeholders to join a working group that will be responsible for facilitating, monitoring and, ultimately, evaluating the implementation of the strategic agenda.

The terms of reference and working methods of this group will be agreed by the members and endorsed by the Parliamentary Secretary for Health.
The working group should also include representatives of relevant technical units ofthe Regional Office, as well as the strategic partnerships desk officer for Malta, who may be asked to join the meetings by modem communication means when and as required and according to which strategic priority is being discussed by the group.
The working group should commit to meeting at least twice a year, or whenever the national counterpart deems it necessary for the group to assess progress, development and the degree of implementation of the strategic agenda, in order to highlight strengths, identify potential gaps and weaknesses hindering implementation and set priorities for future investment on matters of mutual interest.
The working group may also need to meet simply to ensure more accountability and transparency or to align the resources available to the priorities addressed at that particular point in time.
41 • 6.3 Evaluation of the CCS The WHO national counterpart, with the support ofthe Regional Office and, if and where necessary, WHO headquarters, in full coordination with the Ministry for Energy and Health and other partners should ensure the effective evaluation of the CCS, as well as the contribution of WHO to the achievement of the national priorities.
A review of the CCS will be undertaken at the midway point and towards the end of the six-year cycle, to coincide with other national review processes in the country, as relevant.

The review should have a precise focus to determine whether and which outcomes have been achieved through the CCS implementation and the results at the country level.
During this review, attention will be given to ensure that each strategic priority remains consistent with the national development plan and/or national health policy, strategy or action plan.

It will also be important to ensure that there is no need to change priorities, particularly in specific situations, such as when the country faces an emergency or crisis situation.
Identifying if the implementation under way is leading or has led to positive results at the country level and whether the strategic priorities have been achieved in relation to the country priorities is another significant factor.
6.4 Conclusions and recommendations Once the evaluation is completed, the working group will report back on the main achievements, shortcomings and challenges and will make appropriate recommendations to help ascertain whether there has been satisfactory progress and whether resources are .

adequate to ensure timely delivery of the defined outputs.

At the midway point, if any changes are necessary, they should be discussed and, where possible, integrated into the final objectives.
At the end of the CCS implementation, any lessons learned from the monitoring and evaluation of CCSs should be prepared with WHO and shared both nationally and also with other countries, particularly within similar country groupings.

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