More for less: Providing care for an ageing population while reducing costs

Significant strides have been made in improving health indicators, particularly in terms of maternal and child mortality rates. The Ministry of Health (Ministère de la Santé, MS) launched its 2012-16 action plan with a focus on maternal and child heath care. Moreover, to help Morocco reach the objectives outlined in the Millennium Development Goals (MDG) by 2015, a new national plan was launched in November 2013 as part of a broader regional initiative conducted by the World Health Organisation (WHO), the UN Children’s Fund (UNICEF) and UN Population Fund (UNFPA) and involving 22 countries. The plan targets improvements to maternal and child health care and aims at accelerating the progress on indicators in these areas. Nevertheless, the sector remains constrained by numerous obstacles, notably insufficient public funding.

Although public health care spending per inhabitant increased annually by 12.2% between 2001 and 2010, total spending accounts for just 6.2% of the national budget and out-of-pocket expenditure remains considerably high, accounting for about 53% of spending, due mainly to the cost of buying medicines. Extending access to health services should reduce the burden on households. A 2011 constitutional amendment enshrined access to health care as a basic right and the authorities are working to expand coverage.

INSURANCE: The Medical Assistance Regime (Régime d’Assistance Médicale, RAMED), financed by the MS, was introduced in the region of Beni Mellal in 2009, and as of 2012 the scheme has been extended to the rest of the country. The scheme, which is financed by the Social Cohesion Fund (Fonds de Cohesion Sociale, FCS) established in 2011, aims at providing 8.5m impoverished people – around 27% of the total population – with medical insurance to enhance access to medicines and health care services. As of end-2013, around 7m people were benefitting from RAMED coverage. While the RAMED programme is expected to provide coverage to more than a quarter of the population, another 23% are insured under the state-financed, employer-based health insurance firm, Assurance Maladie Obligatoire. Initiated in 2005 through the national Social Welfare Fund, which covers 10% of citizens, and the National Social Security fund, which insures 10-13% of Moroccans. Another 6-7% are insured through private insurance firms. The remaining 43%, however, considered “independent workers”, do not benefit from any coverage. The authorities are currently looking into ways of absorbing the uninsured population, a task likely to prove challenging given the significant size of the informal sector in Morocco.

A number of development organisations have come to support Morocco over the years in realising its goal of achieving universal health coverage. The African Development Bank approved a €115m loan in December 2013 to help finance the third phase of Morocco’s programme to reform medical coverage (Pprogramme d’Appui à la Réforme de la Couverture Médicale, PARCOUM III), set to be rolled out in 2014. While the first and second phases, launched in 2002 and 2006, respectively, aimed to strengthen coverage for formal sector employees and improve access to health services for RAMED members, this phase aims to support basic coverage reforms and provide workers in the informal sector with some form of health insurance. Similarly, in August 2013, the EU, which has supported the implementation of PARCOUM since its inception, approved a €50m loan to fund efforts to extend health services and enhance the RAMED scheme.

MATERNAL & CHILD HEALTH: Maternal and child health has significantly improved in recent years. The maternal mortality rate dropped by two-thirds between 1990 and 2010, while child mortality for under- fives fell by 60% between 1990 and 2011. Nevertheless, these rates remain higher than in neighbouring countries with similar levels of GDP per capita, like Tunisia and Egypt. One of the main reasons behind this is the inequality in health care provision in urban and rural areas; there are around 148 deaths per 100,000 births in rural areas as opposed to 73 deaths per 100,000 in urban areas. Only 55% of births in rural areas are medically assisted, a rate the government is seeking to raise to 75% by 2016. Under the plan, launched in November 2013 by the MS in collaboration with the WHO, the 2015 objective is to bring maternal and child mortality rates down by 82% and 70%, respectively, compared to 1990. The plan targets nine specific regions, home to 66% of the population and where access to maternal and child health care services remains uneven. The plan aims to accelerate current efforts to extend services and enhance quality health care for mothers and children through free medical visits, improved equipment and infrastructure, medical staff training and better transportation to medical facilities.

INFECTIOUS DISEASES: Vaccination policies over the years have considerably contributed to the eradication of communicable diseases. Nevertheless a number of ailments are still prevalent, notably tuberculosis. “Tuberculosis remains problematic for Morocco. However, the disease has been localised and the affected pockets of the population are well enough identified,” Yves Souteyrand, WHO representative in Morocco, told OBG. The MS launched an action plan (2013-16) in October 2013 to fight the disease, for which more than 27,400 new cases were registered in 2012. The Dh250m (€22.2m) plan aims at reducing the prevalence of the illness by 6% a year and increasing the case detection rate to 95% by 2016. Although HIV infection still abounds, the incidence is low compared to other Arab countries. According to figures released by the Pan African AIDS Organisation, an estimated 29,000 people, or around 0.1% of the population, are infected with HIV in Morocco. AIDS awareness campaigns in Morocco were launched as early as the 1990s, allowing treatment centres to emerge to support patients.

In 2012, the country launched a five-year strategy to decrease the number of infected people and reduce the mortality rate by 60% by 2016 by providing additional support, increasing the number of detection and treatment centres, and enhancing prevention.

CHRONIC DISEASES: The eradication of communicable diseases has resulted in higher life expectancy at birth, rising from an average of 47 in 1962 to 70.6 in 2012 (72.5 for women, 68.9 for men). Nevertheless, Morocco’s ageing population has to face the burden of chronic and emerging diseases, which account for around 75% of deaths today, as a result of improved longevity and changes in habits and lifestyles. Some 18.2% of Moroccans suffered from chronic diseases in 2011, up from 13.8% in 2004. Diabetes, hypertension, cancer, and cardio-vascular and kidney diseases are among the main health burdens in terms of chronic illnesses. Between 30,000 and 54,000 new cases of cancer alone are identified every year.

There have been significant strides in prevention and treatment of the disease, however, the fight against cancer has been backed by the Lalla Salma Foundation in particular. Established in 2005, the foundation has taken part in devising a strategy to fight the disease and setting up diagnosis and treatment centres nationwide. In October 2013, the foundation inaugurated a breast and uterine cancer screening and early detection centre in Mohammedia. The Dh4m (€355,000) project was carried out by the foundation, the MS, the National Initiative for Human Development, the region of Greater Casablanca and the commune of Mohammedia. The centre is expected to offer services to the populations of Mohammedia, Bouznika and Benslimane. Moreover, a new Institute for Cancer Research has also been under construction since November 2013 at the Hassan II University Hospital Centre in Fez. The Dh14m (€1.2m) project was launched by the foundation in collaboration with the Ministry of Higher Education and Research and the MS.

GERIATRICS & MENTAL HEALTH: With slowing population growth, lower fertility rates and longer life expectancy at birth, Morocco is looking to address current and potential needs of its ageing population. The number of people aged 60 and older increased from 1.8m in 1994 to 2.3m in 2004, and the group is expected to reach 3.2m in 2014 and 4.1m in 2020. Therefore, a new national strategy has been devised to promote mental health care to improve the quality of services, enhance training of medical personnel, establish partnerships, review the legal framework, and adopt a new drug policy. To increase the in-patient capacity of psychiatric hospitals and expand the current number of available beds from 800 in 2014 to 3000 by 2016, the country has embarked on a plan to construct several new facilities that will accommodate these patients.

One of the latest arrivals includes the new mental and psychiatric health centre which was inaugurated in June 2013 at the Mohammed VI University Hospital of Oujda. The Dh40m (€3.6m) project extends over 7500 sq metres and has a capacity of 108 beds. The new centre includes departments dedicated to psychoneurosis, emergency and consultation services, as well as specialised services in child psychiatry, geriatric psychiatry and psycho-physiology, and addiction. The facility also includes a centre devoted to training doctors and nurses. To accommodate these new arrivals, plans are under way to boost training of mental health professionals to meet the current shortages in personnel with the aim of adding an additional 30 psychiatrists and 185 psychiatric nurses every year. Another centre devoted to geriatric psychiatry was inaugurated in July 2013 in Ar-Razi hospital in Salé. The Dh5.5m (€488,000) investment spans an area of 1100 sq metres and provides services in psychiatric care based on individual and group therapy approaches and includes a day hospital for conventional medical and psychiatry, as well as services in physiotherapy, psychotherapy and music therapy. Under the government’s strategy to enhance mental and geriatric health, three more psychiatric hospitals are expected in Agadir, Kenitra and Kelaa Sraghna, in addition to three facilities specialising in child psychiatry in Rabat, Fez and Marrakech.

PRIVATE CARE: The private health sector comprises 373 private clinics accounting for around 10,300 beds. “The private sector is increasingly taking part in the treatment of chronic and emerging diseases,” Mohammed Hamouiyi, former head of the emergency department at the MS, told OBG. The treatment of chronic kidney disease in particular has involved a great deal of collaboration with private sector operators as the public sector has been unable to meet demand for treatment in this specialty alone due in large part to limited inpatient capacity in dialysis centres and a lack of qualified personnel. To this end, a strategic partnership was signed between the private sector and the Association of Moroccan Nephrologists in 2009 to enhance collaboration between both parties in providing affordable treatment to patients suffering from chronic kidney disease in private dialysis facilities.

Sums allocated by the MS to support the implementation of the programme have increased since 2009, from Dh60m (€5.3m) to Dh200m (€17.8m) in 2013, benefitting more than 2250 patients. However, with private sector operators located mainly in and around big cities and along the coast, disparities in health care provision and specialties remain. According to WHO’s Souteyrand, this is one of the causes holding back the development of general medicine (see analysis).

In 2012-13, a new strategy was introduced to encourage public private partnerships (PPP) in rural parts of the country, through monthly paid contracts established with general and specialist practitioners in the private sector, granting the right and opportunity to carry out a number of hours in the public sector and particularly in emergency services (see analysis). “On the one hand, these contracts allow doctors in remote areas of the country with low consultation rates to increase their revenues, while on the other hand, they contribute to enhancing overall health coverage and emergency services in particular,” Hamouiyi told OBG.

MEDICAL STAFF: Ensuring sufficient numbers of qualified medical personnel is one of the main challenges facing Moroccan health care. Figures from the MS indicate there were 0.62 doctors for every 1000 inhabitants in 2012. Moreover, unequal distribution – with most medical personnel located between Casablanca and Tangiers – makes the situation in rural areas even more difficult than even these figures suggest.

“The insufficient number of staff serving in the health care sector is a crucial challenge for Morocco, one which is expected to worsen due to the anticipated retirement of an significant number of doctors and paramedics in the coming years,” Hamouiyi told OBG. The year 2014 alone is expected to see a deficit of 9000 doctors and 15,000 paramedics if compared to WHO norms. The shortage is partly due to the limited number of jobs created; these have stagnated over the past 15 years due in large part to the shortage of funds allocated to the sector. As a result, the annual increase in doctors and nurses has been 4.7% and 1.9%, respectively, since 2004. Medical staff leaving to work in the private sector can be seen as another reason behind low staff numbers in the public sector.

The private sector accounts for 40% of specialised doctors. There is an increased need for general practitioners, who, reluctant to be assigned to jobs in remote areas of the country, opted instead to pursue further training and specialise. The fact that women are also occupying a growing role in the health sector makes it harder to assign them to remote areas of the country, which are more conservative. The problem is so severe that a number of public health centres have been compelled to shutter due to lack of medical staff. Training programmes to boost the number of health care staff have been launched by the MS with the aim of adding 3000 new doctors annually, bringing the national ratio up to 10 doctors per every 10,000 people by 2020.

MEDICINES: Access to medicine has improved, especially since the advent of RAMED, by which patients are encouraged to seek free medical care. Nevertheless, domestic consumption remains low with annual spending per citizen totalling around Dh400-500 (€36-40), compared to €61 in Algeria and €98 globally. This is mainly attributed to the fact that medicine in Morocco remains expensive, swallowing up more than 50% of household expenditure on health care. The average cost is two to three times higher than it is in neighbouring countries due in large part to fragmented supply and distribution, as well as a low penetration rate of quality generic drugs (30%). In a bid to ease the burden on households and increase access to medicine, the prices of hundreds of pharmaceuticals have been reduced by the government in recent years. According to Souteyrand from the WHO, the price reduction are likely to have an effect not only on citizens’ access to medication and consumption levels, but also on the total spending of health insurance funds.

Better medical coverage is essential in order to improve access to medicine and health services. “Reducing prices on medicine is a coherent and logical policy. However, enhanced medical coverage is necessary to allow the policy to meet its ultimate goal of boosting access to medicine,” Sanaa Sayagh, pharmacist at Swiss firm Roche, told OBG. A new decree determining the price reduction mechanism was adopted in December 2013 and an additional 700 to 800 medicines should see their prices further reduced in 2014.

PHARMACEUTICALS: To meet rising demand for medicine, an increasing number of pharmaceuticals firms have established themselves in Morocco over the years. According to the Moroccan Association for the Pharmaceutical Industry, the total number of manufacturing units increased from 13 facilities in 1975 to 32 in 2011. Today, local production supplies around 70% of domestic demand. Recent years have seen firms penetrating the market through partnerships with local operators. For instance, in October 2011, Jordan-based Hikma Pharmaceuticals acquired 63.9% of Morocco’s Promopharm for $111.2m, and in early 2012, the company increased its share to 94.12%. In September 2013, Emirati Abraaj Group announced an investment (no financial details were disclosed) in Moroccan firm Steripharma that is expected to help the local firm expand and develop its exports towards North and sub-Saharan Africa. Indeed, although total exports account for only 10% of production, a number of locally manufactured Moroccan medicines are exported to the African market. While the impact is slow to manifest itself, the price reduction policy is bound to have a drawback effect on pharmacists and pharmaceuticals firms as a result of declining margins. “Investments are likely to be limited in the first couple of years to the most essential and necessary upgrades until firms regain financial balance,” Roche’s Sayagh told OBG.

OUTLOOK: Overall health care indicators have witnessed demonstrable progress, particularly maternal and child health care, and RAMED has considerably improved access to free medical services for the most vulnerable. The expansion of rural health care, notably emergency services, should contribute towards reducing the disparity in service provision throughout the country. Costs, however, are likely to remain a major obstacle and ongoing negotiations to extend insurance coverage to include the uninsured represent a crucial factor in determining universal access to health care services. Funds allocated by the government will also determine the capacity to acquire medicine, invest in health infrastructure and expand medical staff numbers. Furthermore, in light of the rising longevity, it is expected that chronic diseases and elderly care will increasingly become prominent features of the sector’s future, creating new challenges and opportunities.