1. Access to Treatment Ethical Issues
Mary Anne Ciappara

2. Challenges Ageing population; Unhealthy lifestyles;
Environmental factors;
Increasing patient awareness and patient expectations;
Innovative medicines and interventions;
New technologies

3. New strategies
These Challenges necessitate the adoption of new strategies so that society will have access to a health care system that
Is sustainable
Enable patients to have access to treatment that they need,
Is based on the principles of solidarity and justice
Involve partnership with all stake holders
Enable patient empowerment and patient responsibility

4. Rationing
distribution of limited resources according to specific criteria where needs of recipients are fairly uniform and predictable e.g. Foodstuffs. (implies a just and equitable distribution)
deliberately restricting access to needed and beneficial resources on the grounds of costs alone.

5. Model
That expresses a firm commitment of solidarity and enable patients in their state of vulnerability to have access to medicines that not only add years to life but also improve their well-being.
social ethic cannot simple be a matter of aggregating individual benefits (utilitarian grounded cost-benefit analysis).
Distribution of resources should be made on the bases of need.
Pellegrino E. Justice in Health Care

6. Ethical principles Justice (giving everyone his due)
-everyone should have equal access to treatment needed to maintain health, to cure a disease or to manage a chronic condition.
Access to treatment should be based on medical need. (Pellegrino, Access to health care.)

7. Ethical Principles Solidarity
“unity of fellowship arising form common responsibilities and interests”. Standing together to deal with ‘life misfortunes’
Responding by contributing to the needs of patients in their state of vulnerability to have access to medicines to
improve their well being (not only add years to life but life to years;
enhance people's chance of reaching a normal lifespan and to enable them to live longer;
enable people to maintain an active meaningful life;
protect an individual's share of the normal opportunity range .

8. Ethical Principles Prioritization
“The establishment of rank among other things”
more important to prevent, cure or compensate for those disease conditions which involve a greater curtailment of an individual's share of the normal opportunity range than to treat those conditions that affect it less.
Priority given to treatment which can prevent serious health repercussions that translate to expensive, invasive tertiary care and a negative impact on patients quality of life

9. Ethical Principles Individual Responsibility
-it is not a social obligation to provide health services which arise from individual preferences and not necessary to restore a person's normal functioning

10. Social Security Act Amendments in March 2012
Conditions eligible for free medicines under Schedule V have been extended
These include
- Dementia, COPD, depression and Diabetes

11. Social Security Act
Welcome amendments , however there was no consultation with Chamber and other social partners on the much need reforms.
Indeed
Consensus conference “ A National Agenda for Sustainable Health Care (Feb 2000)
called for the establishment of a Health Authority with representation of all stake holders not least patients and NGOs to spear head reforms in health system. (Bannister and Jonsson,2001.

12. Implementation
No involvement of stake holders in the implementation of changes.
In case of diabetes health care professionals
received circular regarding ‘Diabetes Management and Schedule V application,
Followed by another circular stating that existing patients who receive diabetic treatment on pink card do not need to apply for Schedule V
Conflicting messages being passed on to patients.
No information and education given to patients

13. Involvement of Social Partners
Representatives of stakeholders including patients and NGOs at the decision making level
In the implementation of policies
To evaluate requests for the introduction of new medicines and inclusion of new indication taking into consideration scientific evidence obtained form the maximun possible sources
(Malta Chamber of Pharmacists, 2002

14. Innovations
The present system does not satisfy patient’s needs and requires revisiting as it limits access to innovative, expensive medicines, in line with international trends for the treatment of diseases and conditions based on
evidence based
Safety
Cost effectiveness
Improvement in quality of life

15. Support given to those with ill-health should not be rationed to control expenditure on:
innovative, expensive medicines for the treatment of few patients with terminal or debilitating diseases and rare diseases; and
treatments which can prevent serious health repercussions that can translate into expensive, invasive hospital-based treatments later on in life and a negative impact on patients' quality of life.

16. Second line agents need to be on the formulary.
In situations whereby a patient fails 1st line therapy because he or she is a non responder a second line treatment needs to be available
Example
Introduction of different thienopyridines and other agents for Acute Coronary Syndromes

17.   A good health system is one in which innovative products find themselves into hospital formularies months post-launch. 
For Example
Introduction of DDP4 for management of diabetes to prevent complications
Introduction of insulin analogs basal and premixes for type 2 diabetes where control or compliance are a problem and/or prevent hypoglycaemia