Out-of-pocket payments lead to catastrophic health spending in nearly 1 in 14 households (7%) in Malta, a new WHO study shows. Despite efforts to strengthen affordable access to health care, gaps in health-care coverage remain, pushing many to pay out of pocket, especially households with low incomes.
“Can people afford to pay for health care? New evidence on financial protection in Malta 2025” is the first comprehensive analysis of affordable access to health care in Malta. The study shows that the incidence of catastrophic health spending is higher in Malta than in many European Union (EU) countries.
People who experience catastrophic health spending may not be able to pay for other basic needs such as food, housing and heating. Catastrophic health spending is significantly higher than the average in the poorest fifth of the population (22%) and among households headed by older people (14%). This is concerning given the rise in poverty rates among older people in the last 10 years.
For the poorest households, catastrophic health spending is mainly driven by outpatient medicines and outpatient care. For richer households, dental care is the largest driver of financial hardship.
Despite these challenges, unmet need for health care, dental care and prescribed medicines is below the EU average in Malta. Income inequality in unmet need has declined since 2017 for health and dental care but remains an issue for prescribed medicines.
Strengths in Malta’s coverage policy
Some features of coverage policy in Malta help to strengthen financial protection and serve as examples of good practice for other countries.
- Entitlement to publicly financed health care is based on residence: all residents are automatically covered – including refugees and migrants granted special protection status or a specific residence authorization – ensuring almost all the population is covered.
- There are no user charges (copayments) for covered health care: services included in the publicly financed benefits package are free at the point of use, which means covered health care is affordable for everyone.
- The publicly financed benefits package offers good coverage of outpatient visits, diagnostic tests and inpatient care.
Gaps in coverage persist
However, some aspects of coverage policy are likely to undermine financial protection, particularly for households with low incomes.
- People with chronic conditions or low incomes are entitled to publicly financed outpatient prescribed medicines through the yellow or pink card schemes. Around a third of the population benefits from these schemes, but everyone else pays the full price of outpatient prescribed medicines out of pocket.
- The yellow and pink cards aim to protect people with chronic conditions and low incomes, respectively, but coverage gaps remain, particularly for households with low incomes. Only 3% of the population has a pink card; yellow cards only cover the cost of outpatient prescribed medicines for eligible conditions; and yellow and pink cards only cover medicines in the formulary.
- High medicine prices compound the problems caused by gaps in the coverage of outpatient prescribed medicines.
- Coverage of non-emergency dental care, optical care and medical products is limited in scope in the publicly financed benefits package.
- Long waiting times are an issue for some diagnostic tests, outpatient specialist visits, emergency care and elective surgery, and have become a bigger challenge since the coronavirus disease pandemic, pushing people to access care in private settings.
Improving financial protection in Malta
To improve affordable access to health care and reduce unmet need, particularly for households with low incomes, Malta can:
- find ways to improve protection from out-of-pocket payments for households with low incomes, for example, by leveraging existing means-testing mechanisms. The pink card scheme only covers 3% of the population and is also limited in terms of the medicines and medical products it covers;
- use digital solutions to monitor the types of outpatient prescribed medicines households are spending on to inform policy options that can reduce out-of-pocket payments and improve financial certainty for all households;
- extend publicly financed coverage of non-emergency dental care to those who would benefit most in the short term, such as pregnant women and pink card holders; and
- expand publicly financed non-emergency dental care to include services beyond the current ones provided.
Building on recent efforts, the Government can also continue to lower the price of outpatient medicines and address long waiting times for publicly financed outpatient care. These policy choices can be supported by increasing public spending on health and strengthening the commissioning of publicly financed health care so that public resources are better able to meet equity and efficiency goals.
About the report
This review assesses the extent to which people in Malta experience financial hardship that prevents them from accessing health care, or experience financial hardship when they use health care. It covers the period from 2008 to 2025 using:
- data from household budget surveys carried out in 2008 and 2015 (the latest available year; a new survey is currently underway but data from the new survey will only be publicly available at the end of 2026);
- data on unmet need for health care up to 2023 (the latest available year); and
- information on coverage policy (population coverage, service coverage and user charges) up to January 2025.
“I am glad to see this first-ever report on financial protection for Malta being published. Coverage policy in Malta has some highly protective features, yet out-of-pocket payments do remain a challenge and require policy attention, particularly for people with low incomes and older households,” said Dr Natasha Azzopardi-Muscat, Director of the Division of Country Health Policies and Systems at WHO/Europe.
“Data from the next round of the household budget survey (due at the end of 2026) will provide more up-to-date evidence, but this report gives clear guidance on steps that can be taken now. WHO/Europe will continue to stand alongside the health authorities to strengthen financial protection in Malta’s health system.”
About WHO/Europe’s
work on affordable access to health care (financial protection)
WHO/Europe monitors financial
protection through the WHO Barcelona Office for Health Systems Financing, using
regional indicators that are sensitive to equity. Financial protection is
central to universal health coverage (UHC) and a key dimension of health system
performance assessment. It is an indicator of the Sustainable Development
Goals, part of the European Pillar of Social Rights, and at the heart of the
European Programme of Work, WHO/Europe’s strategic framework.
Explore our data and
analysis on “UHC watch” – a digital platform tracking progress on affordable
access to health care in Europe and central Asia.