Maria Aurora Fenech and Roberta Sultana (Department of Gerontology and Dementia Studies, University of Malta)

Malta’s Long-Term Care system is characterised by a fragmented mixed-economy model, with significant reliance on family and informal care, a multi-ministerial public framework, and expanding private sector participation (1,2). Service delivery for older persons is primarily distributed across the Ministry for Health and Active Ageing and the Ministry for Gozo and Planning (1,2,3). Additional support for older persons with disabilities or complex social needs may also involve the Ministry for Inclusion and the Voluntary Sector.  The population of Malta and Gozo reached 574,250 in 2024, with 18.4% aged 65 and over, reflecting a rapidly ageing society (4). In 2024, 39.0% of individuals aged 65 and over in Malta reported experiencing at least some long-standing activity limitation, indicating a substantial potential need for long-term care support (5).

While Malta maintains a strong cultural preference for ageing in place supported by extensive community-based services including domiciliary care, telecare, and subsidised live-in carers, the system faces substantial challenges, with significant demand for residential care continuing to outpace available capacity despite ongoing government efforts to procure additional beds from private providers (1,6). The system is financed through general taxation, though public expenditure has historically remained below the EU average, combined with significant out-of-pocket payments. Older persons residing in publicly funded residential long-term care contribute between 60% and 80% of their pension towards care costs depending on the resident’s care needs and level of dependency (2,3).This creates a stratified system where access to quality care depends largely on financial resources and family support networks, with informal carers, predominantly women, experiencing negative health impacts while providing unpaid care (6,7).

LTC responsibility is divided between the Ministry for Health and Active Ageing and the Ministry for Gozo and Planning, with no unified national framework (1). Prior to 2024, health and active ageing were administered by two separate ministries, the Minister for Health and the Minister for Active Ageing. Following a cabinet reshuffle in January 2024, both portfolios were merged under a single minister, the Ministry for Health and Active Ageing, supported by a Parliamentary Secretary for Active Ageing (8). The Active Ageing and Community Care (AACC) operates as the principal statutory body for both residential and community-based services across Malta and Gozo (9).  However, the involvement of a separate Ministry for Gozo and Planning in LTC governance means that ministerial responsibility remains divided across the two islands (1).

Provision: Care is delivered through a mixed system of state, Church-run, and private facilities, all operating under the AACC’s public-private partnership framework, through which the state purchases beds from licensed providers (1). All providers must be licensed by the Older Persons Standards Authority (OPSA), established in 2023 as the dedicated regulatory body for geriatric services (12). The Catholic Church remains a significant provider, though it faces sustainability pressures from declining numbers of religious care staff (13). Self-funded residents in private facilities pay market rates outside the state fee structure set under Legal Notice 151 of 2018 (1).

Reform: A comprehensive statutory LTC framework is under development, launched June 2025 under the European Commission’s Technical Support Instrument with WHO guidance. The initiative covers building an evidence base, co-developing a legal framework through multi-stakeholder engagement, and strengthening monitoring capacity (14). Legal Notice 151 of 2018 remains in force pending the outcome of this process.

In line with the LTC governance structure, LTC financing is characterised by a complex administrative framework with multiple funding pathways. There are separate funding streams for health and social care components, which are distributed across multiple government departments (3). Public financing is substantial but below the European average, with Malta spending 0.9% of GDP on public LTC expenditure compared to the EU average of 1.6% (3,15,16,18). The system operates on a mixed universal and means-tested basis. Public revenue is raised through national taxation and social insurance contributions, with employees and employers each contributing 10% of gross salary to the social security system (15,17). Private LTC insurance plays a minimal role in the system.

Residents in state-financed residential care contribute according to their assessed level of care. Those receiving Level 1 care contribute 60% of their pension and other income, while those requiring Level 2 care contribute 80% of pension-related income and 60% of other income, subject to a minimum amount retained for personal use (15,17). Private care homes provide premium services and amenities, operating outside the public funding framework. They require full private payment for their premium services and amenities and their monthly fees can be substantial compared to subsidised public or PPP arrangements (12).

Home and community care services in Malta are largely publicly subsidized and supplemented by informal support from family and friends. The services include home-based care, day centres, and social support. Eligibility for free or heavily subsidised care is often determined by criteria such as age, disability, or possession of a “pink form,” with some services requiring only a nominal fee or a means-tested contribution. The Pink Form, formally known as Free Medical Aid under Schedule II of the Social Security Act (Chapter 318, Laws of Malta), is a means-tested entitlement issued by the Department of Social Security that grants eligible individuals access to free medical services, medications listed on the Government Formulary List, and a range of related welfare benefits.

Informal unpaid care represents a substantial and largely uncosted economic contribution to Malta’s long-term care system. Modelling suggests that a shift from informal to formal care would require a disproportionately large increase in public expenditure relative to the EU average. This underlines how heavily the system relies on unpaid family care (6).

Malta’s long-term care system is centrally regulated, aiming to ensure high standards of safety, quality, and dignity for older persons (3,6). The Older Persons Standards Authority (OPSA), established by the 2023 Act, serves as the main regulator for all long-term care services across Malta and Gozo (19). OPSA regulates all residential and community facility-based services for older persons, including care homes, day centres, dementia-related services, and respite care, regardless of whether they are public, private, or church-run (12,19). The Authority sets, publishes, and regularly reviews regulatory standards, grants and renews licences, and conducts regular unannounced inspections to ensure compliance and can suspend or revoke licenses if standards are not met (12,19). OPSA also investigates complaints and maintains a register of individuals convicted of abuse against older persons, aiming to provide robust oversight and assurance of quality (20).

While OPSA publishes its standards and inspection processes, there is currently no public system of formal quality ratings for providers. However, the Authority ensures accountability and encourages feedback from service users and the public, promoting continuous improvement in the sector (12).

Eligibility is determined separately for residential LTC and for community-based services. For publicly funded residential LTC eligibility is determined through a comprehensive, regulated and standardised assessment process conducted by a multidisciplinary team and guided by national regulations and standards. These national criteria and assessment instruments apply uniformly to both state-run and Public-Private Partnership (PPP) residential care homes (1,21). The assessment considers the applicant’s medical condition and dependency levels, supported by a medical report from their General Practitioner detailing health, functional abilities, and cognitive challenges, as well as age (generally over 60, with exceptions for younger individuals with significant disabilities (2). The team also evaluates social and psychological well-being, quality of life, mobility, and the ability to perform Activities of Daily Living (ADLs) independently (1,21).

Additionally, the assessment team reviews the availability and adequacy of informal support from family or the community, verifies citizenship or residency status, which may be required for some state-funded services, and assesses the urgency of care needs, which can influence waiting times and prioritisation (1). There are two residential care tiers: Level 1, providing minimal basic residential care for older persons who can no longer live independently in their own home in the community, and Level 2, providing high dependency chronic care for those with more complex needs, primarily delivered at St Vincent de Paul (1,21). Both tiers are determined through interdisciplinary assessment for persons generally aged 60 and over where home living is no longer suitable (21,22,23).

To apply for public community services which are provided by Active Ageing and Community Care (AACC) in Malta, individuals must apply through the AACC. Eligibility is determined by the specific service being applied for. Some services require a medical or needs assessment prior to access, which is carried out by an AACC healthcare professional to ensure the service is provided according to need. Most services also require a completed application form accompanied by a medical report signed by the applicant’s general practitioner, and AACC reserves the right to request any additional documentation as required (10).

For individuals younger than 60 with care needs, services are available through agencies under the Ministry for Inclusion and Voluntary Service, such as Aġenzija Sapport, which provides support to persons with physical and/or intellectual disabilities. Eligibility typically requires a disability card, and services include personal assistance, social work support, and financial subsidies for carers, with access determined through individual assessment (24).

The orientation of Malta’s public long-term care system reflects a dual approach, with a strong tradition of residential care but a growing policy emphasis on expanding community-based services and supporting ageing in place. Service delivery is primarily offered through in-kind support, complemented by targeted cash benefits that focus on those most in need within community-based care arrangements, rather than through universal financial assistance. Malta’s policy on active ageing follows a “bottom-up” approach via a range of innovative community care services, such as night shelters, handyman services, and the Live-in Carer scheme, all designed to ensure that frail older persons can age in place for as long as possible (1,6).

The Carer at Home Scheme offers financial assistance to families employing qualified carers, and professional respite care delivered both at home and in dedicated facilities. Service providers include public entities such as the Active Ageing and Community Care (AACC) directorate, private companies contracted by public commissioners, directly purchased private services, non-profit organisations, community groups, and religious organisations (11,32,33).

Support for unpaid carers and informal workers in Malta includes a range of measures designed to ease the demands of caregiving and improve carers’ well-being (6). The Malta Dementia Society, a non-governmental organisation and member of Alzheimer Europe, plays a complementary role by providing carer support groups, community awareness programmes, and advocacy, and was instrumental in driving the development of Malta’s national dementia strategy (25,26).

Malta offers two main types of cash allowances for informal carers. The Carer’s Allowance is payable to individuals over 18 who provide full-time care to one or two relatives with low dependency living in the same household, with payments issued every four weeks and an increased rate available for those caring for more than one person as of 2025 (28). The Increased Carer’s Allowance is available for those providing care to relatives with high dependency (29). Both allowances include social security contribution credits, helping carers maintain their pension entitlements despite time spent out of the formal workforce. Hence, Malta’s LTC cash benefit system is characterised by targeted support mechanisms, primarily through carer allowances for informal caregivers, rather than comprehensive universal cash benefits available to all LTC service users. There are also targeted cash benefits, such as the Carer’s Grant, which awards €4,997 annually to parents who are not in employment and care for a child with a disability over the age of sixteen (30). Persons with a disability may also receive Disability Assistance, a non-contributory weekly benefit available to individuals aged 16 to 65 with physical, intellectual, sensory, or severe disabilities, providing direct financial support to those affected and their families (27). Training opportunities are offered, including a free 10-week Dementia Course for Informal Caregivers, which covers practical skills and knowledge to help family carers manage the challenges of dementia care. Notably, Malta was also the first country globally to adopt the WHO’s iSupport online training programme, providing dementia caregivers with structured, evidence-based support and practical skills (31). Respite care is provided both in the home and in dedicated residential long-term care facilities, allowing carers to take breaks from their duties, with some services offered free of charge or subsidised by public and voluntary organisations. Carers’ leave is a legal entitlement in Malta, granting all employees up to five working days of unpaid leave per year to care for a relative or household member with a serious medical condition, protected under the Work-Life Balance for Parents and Carers Regulations (6). Additionally, social assistance and pension schemes are available for single or widowed carers, subject to stringent means testing. Although support measures for carers exist in Malta, there is currently no formal national register or dedicated organisation representing carers, and most services remain primarily focused on the needs of the care recipients rather than on carers themselves (6,7).

Recent policy developments and pilot projects signal a strategic shift toward community-based care and supporting older persons to remain in their own homes as long as possible. Community-based care for older persons in Malta encompasses a wide range of services designed to support independent living and enhance quality of life. The table below lists the home and community-based care services available (9). While precise national coverage statistics are not publicly available for all services, the expansion of active ageing centres and the introduction of new schemes (such as increased subsidies for home care) indicate growing accessibility and demand. For example, active ageing hubs are open to anyone over 60 and operate in most localities, while respite care and telecare services are increasingly utilised by families seeking support for their older relatives. Overall, the system is designed to be affordable and accessible. (6,9,11).

Table 1: A summary table of key community-based services, descriptions, providers and eligibility/funding (9,10).

In the private sector, Hilltop Gardens Retirement Village in Naxxar stands out as Malta’s first premium retirement village, offering a self-contained community of 133 one- and two-bedroom apartments and penthouses, set within landscaped gardens, and a wide array of amenities including a swimming pool, spa, restaurant, chapel, and a range of activities and 24-hour support services. This model aims to provide residents with independence while ensuring care and support are readily available (34,35).

Malta offers a range of supported housing options for older persons and for individuals with disabilities or mental health needs through both public and private initiatives. The Housing Authority has developed sheltered housing schemes specifically for older persons, usually with small clusters of 8-16 self-contained flats designed for independent living, with a private bedroom, living area, kitchen and accessible bathroom. These units are allocated exclusively to older persons and remain the Authority’s property. However, only a small number of such schemes currently exist (36).

Residential care for older people: Historically, Malta’s public LTC system has prioritised residential-based care, with a significant portion of public resources and infrastructure dedicated to state-run and public-private partnership (PPP) care homes. These facilities provide comprehensive in-kind services, including nursing, allied health, meals, and personal care, and are regulated by national standards. Admission is based on multidisciplinary assessment, and the state subsidises care for those who qualify, although recipients contribute a portion of their income and assets (1,15,17).

Malta’s residential care sector is not dominated by large multinational chains but rather comprises local private operators (with CareMalta Group as the dominant private provider), church-run and non-profit care homes, and public sector homes, together covering approximately 5,000 older persons (33,37,38). Church and non-profit organisations continue to play an important role in the provision of residential care services, operating facilities through various arrangements and partnerships with the state (39).

Malta’s residential care system is characterised by medium to large-scale facilities (40). The government has moved away from smaller facilities, with most homes accommodating between 60-300 residents.

The regulatory framework requires modern standards including the following requirements (41,42):

• Space requirements: Single rooms must have at least 12 square meters, shared rooms require 8 square meters per resident
• Rooms should not accommodate more than two residents (with a maximum of three beds only in exceptional circumstances
• Modern amenities: En-suite bathrooms, nurse call systems, air-conditioning, telephones, Wi-Fi access
• Accessibility: Compliance with Malta’s accessibility standards
• Specialised design: Natural lighting, grab rails, colour-coding for orientation, reduced noise environments

Many facilities are purpose-built modern buildings rather than converted structures, particularly newer developments that must comply with strict regulatory standards for physical environment, safety, and accessibility requirements (41,42). The regulatory framework aims to ensure that all residential care homes, regardless of their original building type, meet contemporary standards for older persons’ care.

Facility-based long-term care constitutes a central component of Malta’s care provision for older persons, organised through a combination of state-administered and partnership-based arrangements (33).

Saint Vincent de Paul (SVP) is a distinctive state-run facility directly administered by the government, which houses more than 1,500 older persons and provides high-dependency chronic care services for individuals with complex care needs.

Residential care for younger persons: Residential care for younger persons in Malta, particularly those with disabilities or specific care needs, is provided by several organizations. For instance, HILA (Home to Independence and Limitless Abilities), part of CareMalta, offers a wide range of services including housing, learning, development, and leisure activities for persons with disabilities, using a person-centred approach. Under the HILA umbrella, several facilities operate including; Casa Apap Bologna; Dar Sant’Anna, Dar Merhba, Casal Nouvo and Santa Rosa. These care homes also offer supported living and tailored care for individuals with disabilities, enabling independence and integration into community life (37).

Dar tal-Providenza is another key provider, dedicated to persons with disabilities who cannot live with their families (39). It offers both permanent and temporary residential services in a family-like environment, aiming to maximize residents’ abilities and independence. The facility caters to individuals of all ages, including those under 60, and provides round-the-clock care and support.​ This organization, founded in 1965 by Monsignor Michael Azzopardi, operates multiple residences like Villa Monsignor Gonzi, Villa Papa Luciani, and small community homes such as Żerniq, Akkwarell, Dar Pirotta, and Shalom in Żurrieq. It focuses on family-like residential care for persons with disabilities.

Dar il-Kaptan, run by the Foundation for Respite Care Services, offers residential and respite care for persons with disabilities, providing a supportive, homely environment with personalized care (43). Moreover, YMCA Malta also operates residential facilities for individuals and families facing social or health challenges, including younger adults, focusing on holistic care and tailored support (44). Fondazzjoni Arka, established in 2000, is another NGO providing residential services, respite care, and community integration for people with disabilities (45).

These organisations, amid others, ensure that younger adults with disabilities in Malta have access to a variety of residential care options that prioritise dignity, independence, and integration into community life. The Social Care Standards Authority serves as the public authority for regulating and licensing social welfare and service providers, including residential care facilities. It oversees areas like people with physical disabilities, mental disabilities, and mental health services through inspections, standard enforcement, and monitoring (42,46).

Malta has made significant progress in fostering age- and disability-friendly environments, guided by its National Strategic Policy for Active Ageing (2023–2030), which emphasises mainstreaming ageing in public policy and promoting the rights and inclusion of older persons (22).

This policy supports accessible public spaces, affordable housing, and transportation, aiming to enhance independence and participation for older persons. At the community level, the Active Ageing and Community Care (AACC) agency provides a wide range of services, as described earlier, that enable older persons to live independently and maintain social connections (20,22). Local councils also play an active role, running dementia awareness campaigns, promoting healthy ageing, and offering specialised staff training to better support older persons.

Community-level initiative further enrich Malta’s approach to age-friendliness. Active Ageing Centres across the country offer older persons opportunities to remain physically, mentally and social active through diverse programs. There are 35 such centres across Malta and Gozo, accommodating over 2,500 regular attendees (9). These centres, managed by the Ministry of Health and Active Ageing promote health, combat isolation and include dementia and community hubs for expanded access (10). Intergenerational projects, such as the “School Grannies” programme, connect older persons with schoolchildren to foster mutual learning and companionship (10). Non-governmental organisations and local councils collaborate on projects to address social isolation and promote digital inclusion of older people (47). These efforts collectively aim to create a supportive environment that values the contributions and well-being of older persons.

Assistive technologies play a crucial role in supporting older persons in Malta, enabling greater autonomy and participation in daily life. The main types of assistive technology available include mobility aids (such as walking aids and wheelchairs), hearing and vision aids, communication devices, and GPS-enabled tracker devices designed for safety, particularly for those living with dementia or mobility challenges (48,49,50). Access to these technologies is facilitated through referrals from healthcare professionals, social workers, or direct engagement with public agencies like the Foundation for Information Technology Accessibility (FITA), the Access to Communication and Technology Unit (ACTU) and the One-Stop-Shop (48,49,50). The Maltese government provides financial support and subsidies for assistive devices, especially for individuals facing economic hardship, through initiatives such as the Assistive Apparatus Fund and grants for special equipment (51,52).

Public and community support is robust, with assessment, training, and ongoing assistance offered to ensure that older persons can effectively use assistive technologies (10,48,50). NGOs, including The Malta Trust Foundation, contribute by providing communication devices for those with complex needs, often in collaboration with ACTU and other partners (48,50). Digital literacy training is widely available through community centres and FITA, helping older persons bridge the digital divide (48,50). User involvement in the selection and evaluation of assistive technologies is increasingly prioritised, ensuring that solutions are tailored to individual needs and preferences. Despite some challenges, such as delayed help-seeking and the need for more opportunities to trial devices, Malta’s system continues to evolve, with a strong focus on accessibility, affordability, and user satisfaction.

Unpaid Carers and Paid Care Workers

Informal unpaid care, primarily provided by family, spouses, partners, and friends (6,7), is a significant component of Malta’s long-term care system. Its economic contribution is substantial and largely uncosted, with research suggesting that a full shift from informal to formal care would require a disproportionately large increase in public long-term care expenditure relative to the EU average (6). Gender dynamics are pronounced, with 37.9% of non-working females in 2023 attributing this to family responsibilities (significantly higher than males), and 18.6% of employed females working part-time (compared to 7.1% of males), of these almost two-thirds citing family or personal reasons for working part-time (53).

Carers provide personal care, household work, and emotional support (6,7), facing physical and mental health impacts, financial burdens, and decreased social well-being (6,7). The system’s reliance on family care is threatened by demographic trends: increasing female labour force participation reduces traditional caregiver availability while population aging increases demand.

Paid care workers comprised 19.8% of Malta’s total employed persons in 2023 (32.7% of women employed and 10.9% of men) (53). Educational attainment is notable, with over half of care workers having tertiary education, 24.9 percentage points higher than the non-care workforce (53). Foreign nationals are over-represented in assisting occupations (53).

Professional Standards and Qualifications for Care Staff in Malta

Direct care staff must possess recognised qualifications, with foreign credentials requiring equivalence assessment through the Malta Qualifications Recognition Information Centre (MQRIC) (42). New minimum standards mandate that all staff speak English or Maltese and require two written references as well as clean police conduct certificates (42). Training mandates include induction within six weeks of hiring, documented foundation training within the first six months, a minimum of three paid training days annually, and performance plans with biannual appraisals for career development (53).

The residential care workforce includes 416 nurses, with specialised palliative care training available among nursing staff to support residents with complex care needs (54).

Professional nurses deliver evidence-based care encompassing assessment, planning, implementation, and evaluation within an interdisciplinary team incorporating physiotherapy, occupational therapy, speech therapy, and nutritionist services (42). Specialised clinical roles require advanced qualifications and experience, reflecting the complex needs of older persons (42,54).

Pay, Conditions, and Workforce Challenges for Maltese Care Workers

Working conditions are characterised by a substantially higher prevalence of shift work than in non-care occupations, by approximately 10.9 percentage points (53,55). Female care workers earn on average €7,622 less per year than male care workers. In 2023, foreign care workers earned an average annual gross salary of €26,474, €4,777 less than their Maltese counterparts (53).

Workforce shortages represent a significant challenge in Malta’s care sector. In 2022, concerns were raised regarding the loss of more than 600 nurses to the UK, contributing to pressures on care homes, which were reported to be operating under significant strain, with staff experiencing burnout across private and public–private partnership facilities (56). Despite existing standards, systemic challenges persist, including understaffing, enforcement gaps, competition for staff across sectors, and language barriers (56).

Workforce Enhancement Measures for Malta’s Care Sector

In response to workforce pressures, government initiatives include the National Health Systems Strategy 2023–2033, which promotes integrated care for older persons (52), and the extension of third-country national nurses’ contracts to three years, aligning their employment terms with those in the public sector to improve workforce stability (56).

Measures to expand the workforce include support mechanisms such as the Carer at Home Scheme funding private carer employment (57) and enhanced minimum standards with mandatory induction, foundation training, and annual paid training days (58).

Recommended policy measures from the Malta Chamber of Commerce prioritise immediate actions: increasing Nursing and Midwifery Council resources to expedite foreign nurse applications, improving residency terms and family reunification for foreign healthcare workers, and incentivising local nurses to join/return to the profession (56). Long-term strategies involve closing gender pay gaps in care work (53), establishing clear career progression pathways (56), and integrating formal/informal care systems to alleviate unpaid carer burdens (6,59).

Development Status and Digital Infrastructure in the Health System

Malta’s health information systems are moderately well-developed, with significant recent investments in digital health infrastructure (52,60). The myHealth service, launched in 2012, allows patients and doctors to access electronic medical records through a nominated doctor and an electronic identification (eID), strengthening continuity of care. The National Health System Strategy gives particular attention to information technology and healthcare information system creation.

Data Linkage Across Health and Long-Term Care

Data linkage capabilities remain limited between health and long-term care sectors. While hospital activity data is available in detail from both public and private sectors, the LTC system relies on limited data collection via OPSA licensing, inspections, and its public register of providers, lacking a centralized national database for clinical outcomes or patient experiences. Hence, significant information gaps persist in areas such as providers’ clinical outcomes, appropriateness of processes, patient experiences, and satisfaction. The health system suffers from fragmentation between hospital and community services, as well as between public and private provision (3,6).

Digital Health Records: Malta is targeting complete digitalisation of residential care homes with paperless patient records by end-2024. A dashboard system for medical records has been introduced at St Vincent de Paul, with plans for rollout across all the older person residential care facilities (52,61).

 Performance Evaluation Systems

Malta established its first Health Systems Performance Assessment (HSPA) framework in 2015, identifying 57 key indicators from an initial 350 performance measures. However, the assessment revealed that the stewardship domain could not be evaluated due to insufficient data (55). Investment in robust management, operational, and clinical information systems is required to effectively measure health system performance (55). The absence of comprehensive information systems remains a significant barrier to systematic performance monitoring across the long-term care continuum (3).

Technology Integration and Digital Innovation

Malta is integrating AI and robotics into older persons’ care through a layered approach spanning technology, policy, and research. Key digital tools include the Telecareplus and Telecare on the Move systems for remote monitoring and emergency response (62,63,64,65), and the myHealth portal for accessing health records (60). Nationally, the AI Strategy 2030 (66), the Digital Health and Health Data Strategy, the Active Ageing Policy 2023–2030, and the National Dementia Strategy 2024–2031 (25) collectively shape the policy framework for ageing, dementia care, digital health, and the wider transformation of health and social care services.

Malta was also the first country to adopt the WHO’s iSupport online training programme for dementia caregivers, while FITA promotes ICT accessibility for older persons and people with disabilities through free local training (48,49).

On the research front, several University of Malta-led projects are advancing technology in older persons’ care, all at an exploratory stage. The HEARTS project pilots semi-humanoid robots to assist healthcare professionals and older persons, aiming to address workforce shortages and improve quality of life (67). The VERA project (EU-funded, Interreg Italia-Malta) uses AI, virtual reality, and wearables for early Alzheimer’s detection (68). The PEM project uses wearable devices to monitor individuals living with dementia and address wandering risks (69). CAIRED integrates AI with smartwatches for home-based cardiac monitoring (70).

Person-Centred Care Models

Enhanced Choice and Flexibility: The Active Ageing and Community Care (AACC) has expanded its Residential Respite Care service, allowing eligible individuals to choose any licensed residential care home approved by the Older Persons Standards Authority (OPSA) based on personal preferences. Clients can book directly with the residential care homes and receive refunds up to €72 per night for a maximum of 63 nights annually (71).

Integrated Palliative Care Strategy: Malta has developed its first National Palliative Care Strategy 2023-2033, providing comprehensive palliative care across all settings for patients with cancer, organ failure, frailty, and dementia. This strategy emphasizes quality of life, dignity, and comfort throughout illness progression (72).

Supporting Policies and Infrastructure

The National Health Systems Strategy 2023-2030 prioritises information technology and healthcare system integration (52). The government has established robust regulatory frameworks through OPSA and the Social Care Standards Authority to supervise and inspect all residential care facilities (12,46).

Coverage: Malta’s long-term care (LTC) system offers universal public coverage, yet persistent waiting lists for residential beds show that state provision is not keeping pace with demand (2).

Private providers face capacity and affordability challenges, with the cost of residential care  limiting access for older persons reliant on minimum pensions (2).

Equity: Access to care is arranged separately for these four groups: self-funded private residents, government-subsidised residents, older persons cared for by relatives, and those relying on non-family live-in carers (2). This segmentation drives inequities, as higher out-of-pocket spending pushes middle-income families toward private primary care for convenience and continuity (2). In this context, private primary care encompasses the practice of families paying out of pocket to consult private general practitioners and specialists, bypassing the public system due to long waiting times and lack of continuity of care. This disproportionality affects middle income families who do not quantify for means-tested benefits but cannot easily absorb these additional costs. Economic shocks linked to the international financial crisis have further increased the financial burden on both formal and informal carers (2,73).

Effectiveness and System Integration: Fragmentation between hospitals, community services, and public–private providers hamper continuity of care and system efficiency (1,74,75). Despite some progress such as memory clinics and single-point access services have improved diagnosis and referrals (3), there are major gaps in the implementation of healthy-ageing policies (75).

A National Audit Office review in 2015 found that minimum nursing and caring times in contracted facilities fell well below agreed standards, a shortfall linked to chronic understaffing and weak enforcement (2,76,77). Since 2017, the Standards of Care Quality Charter and targeted training programmes have led to 416 residential-home nurses completing palliative-care courses, beginning to address these shortcomings (6,54). The 2016 Patient Rights Charter set clearer quality benchmarks (78) but carers, both formal and informal, still require stronger support structures (6,7).

A 2022 audit of community-based and residential care services in Gozo found that, while services such as Home Help and Meals on Wheels generally support older persons’ independence and are cost-effective, several issues persist including undelivered service hours, provision of services outside the home, and limited monitoring. Client satisfaction with Meals on Wheels also declined over time. Residential care homes contributed positively to well-being, but the audit identified rising costs, limited oversight, and unclear strategic direction, emphasising the need for stronger governance, clearer long-term planning, and improved monitoring to ensure care for Gozo’s ageing population remains consistent, equitable, and sustainable (79).

Most recently, a 2025 National Audit Office performance audit of home-based medical and clinical services for older persons found significant gaps in coordination, documentation, and follow-up between community and residential care settings, highlighting the need for clearer service protocols, improved data linkage between providers, and more systematic quality monitoring of home-based care delivery (80).

Resilience

Rapid population ageing, combined with the erosion of traditional family care, intensifies pressure on services (2,6). A 2025 EU- and WHO-supported initiative to draft a comprehensive LTC law aims to strengthen governance and sustainability (14).

Impact on People Who Use and Provide LTC

The COVID-19 pandemic had severe consequences for Malta’s older persons in residential care settings. Residents were confined to their care homes from March 2020, with some restricted to their individual rooms. Despite full vaccination by February 2021, older persons were not allowed outside residential care homes until June 15, 2021, i.e. 15 months after the first COVID-19 case was recorded (1,81).

The pandemic disproportionately affected older persons, with 91.34% of deaths during the second wave occurring in those above 65 years. Social isolation caused significant harm, as older persons required contact with family and friends but were cut off from their support networks (81).

For care providers, the pandemic brought substantial challenges including 40% increased expenses, overtime costs for additional cleaning and coordinating video calls between residents and families, and costs for adapting spaces into living quarters for staff. Many private facilities experienced income drops as admissions and respite services stopped (81).

How the LTC System Coped

Malta’s response was coordinated through the Social Care Standards Authority (SCSA), which immediately classified residential care settings as high-risk and issued comprehensive directives. The system implemented voluntary lockdowns in most residential care homes for 12 weeks, with mandatory testing of healthcare professionals before assuming duties (46,81).

Key measures included close collaboration between the Public Health Authority and SCSA, regular updates on bed occupancy to facilitate hospital capacity management, and prioritised vaccination for older persons (46,81).

Key Lessons Learned

Several critical insights emerged from Malta’s pandemic experience:

• Infrastructure inadequacies: Residential care homes were too large and lacked proper isolation facilities or infection control infrastructure (1,81).
• Policy coordination gaps: Residential care homes received conflicting instructions from different departments, highlighting the need for unified guidance (1,81).
• Communication importance: Regular consultation with the residential care home managers proved essential and must remain ongoing.
• Social isolation harm: The negative impact of isolation on older persons’ mental health demonstrated the need for balanced approaches (81,82).
• Financial sustainability: The pandemic highlighted challenges faced by private and Church-run facilities, necessitating government support models (1,81).

The experience showed that while infection prevention measures like mandatory face masks prevented seasonal influenza, the human cost of prolonged isolation was significant. Future preparedness must balance infection control with maintaining quality of life and human dignity for older persons (81,82,83).

Recent Reforms Adopted and being Implemented

National Strategic Policy for Active Ageing 2023-2030

This policy represents a significant shift toward protecting older persons’ rights and mitigating age discrimination, elder abuse, and social exclusion. The policy emphasises a “twin-track” approach addressing population ageing from both societal and life course perspectives (22).

National Dementia Strategy 2024-2031

Malta has implemented the “Reaching New Heights” strategy, aiming to significantly improve the quality of services for persons with dementia (25,84).

Palliative Care Strategy 2025-2035

Malta launched its first comprehensive Palliative Care Strategy in March 2025, covering a 10-year period (72). This strategy focuses on integrating palliative care early in chronic illness journeys and developing multidisciplinary palliative care teams available round-the-clock. The strategy includes plans for increased in-patient facilities and expanded bedspace for palliative care, backed by government financial commitment.

Major Reforms Currently Under Development

Comprehensive Legal Framework for Long-Term Care

The most significant reform currently underway in Malta is the development of its first comprehensive legal framework for long-term care, officially launched in June 2025 (14). This ambitious project aims to ensure that every older person in need has access to affordable, high-quality services tailored to their specific needs . Funded by the European Union through the Technical Support Instrument (TSI) and supported technically by the WHO Regional Office for Europe, the project is set to continue until 2027 (14). It focuses on three key areas; gathering data and evidence for fact-based policy-making, collaborating with all stakeholders to ensure practical and effective policy, and preparing individuals and institutions for implementation while monitoring progress.

EU Technical Support Instrument (TSI) Projects

Malta has secured significant EU support for reforms, with 42 TSI projects worth more than €15.5 million approved by the end of 2024, and 13 additional projects planned for 2025 (73). These include deinstitutionalisation initiatives through personal budgets and enhanced access to justice reforms (73).

Fenech, M. A. and Sultana, R. (2026). Long-Term Care system profile: Malta. Global Observatory of Long-Term Care, Care Policy and Evaluation Centre, London School of Economics and Political Science. https://doi.org/10.5281/zenodo.21441025

Fenech M.A. LTCcovid country profile – Malta. (2023) In: Comas-Herrera A., Marczak J., Byrd W., Lorenz-Dant K., (editors) International living report on COVID-19 and Long-Term Care users and providers: context, impacts, measures and lessons learnt. https://ltccovid.org/covid-19-and-the-long-term-care-system-in-malta/

Vassallo, M. (2018). ESPN Thematic Report on Challenges in long-term care Malta 2018. European Commission Directorate-General for Employment, Social Affairs and Inclusion. https://ec.europa.eu/social/BlobServlet?docId=19860&langId=en

European Commission, Directorate-General for Economic and Financial Affairs, & Economic Policy Committee, Ageing Working Group. (2019). Joint report on health care and long-term care systems and fiscal sustainability: Country documents – 2019 update Malta (Institutional Paper 105). Publications Office of the European Union. https://ec.europa.eu/info/publications/joint-report-health-care-and-long-term-care-systems-fiscal-sustainability_en

National Statistics Office. (2025). World Population Day: 11 July 2025. https://nso.gov.mt/population/world-population-day-11-july-2025/

Eurostat. (2025). Self-reported long-standing activity limitations (GALI) by sex and age (hlth_silc_28) [Data set]. Eurostat Data Browser. https://ec.europa.eu/eurostat/databrowser/view/hlth_silc_28__custom_17921629/default/table

World Health Organisation (WHO). 2017. Malta: Health system profile. https://www.euro.who.int/en/countries/malta/publication/health-sytem-profile-malta-2017

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2. Vassallo, M. (2018). ESPN Thematic Report on Challenges in long-term care Malta 2018. European Commission Directorate-General for Employment, Social Affairs and Inclusion. https://ec.europa.eu/social/BlobServlet?docId=19860&langId=en
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