Access to health care broadens in Morocco

Health care services in Morocco have evolved in line with the country’s epidemiological transition, facilitated by heightened surveillance of health-related conditions and the maturing role carried out by the private sector. Developments have evolved in line with the objectives outlined in the country’s long-term strategy, Vision 2020. Implemented in 2006, the strategy aims at achieving an efficient health care system by 2020. In its 2012-16 phase, reforms have aimed primarily at consolidating past gains but also addressing new needs, with a particular focus on restructuring emergency services, promoting family medicine, developing rural health care, extending national coverage schemes and human resource development.

Indicators

Maternal health care in particular has improved significantly over the past 10 years, with the maternal mortality ratio dropping from 227 deaths per 100,000 live births to 112, and infant mortality declining from 40 deaths per 1000 live births to 30.2, according to the World Health Organisation (WHO). This can in large part be attributed to efforts targeting better access to maternal and child health care services, as well as increased awareness on the necessity to seek medical assistance throughout pregnancy and after.

Morocco has also made significant strides in reducing the prevalence of infectious diseases, and has eradicated polio, trachoma and malaria, thanks to a variety of programmes to raise awareness on how to treat and prevent communicable illnesses, in addition to expanded vaccination campaigns and the introduction of new medicines into the market. Though largely under control, diseases such as hepatitis are still prevalent and efforts are under way to curb the number of affected patients.

Hepatitis 

While most communicable illnesses in the country are largely under control, hepatitis has proven to be one of the more intractable challenges. Morocco is aiming to be rid of hepatitis C by 2020. An estimated 650,000 Moroccans have the disease, according to local media, but the arrival of new drugs on the market provides cause for optimism. In collaboration with the Moroccan government, Pharma 5, a local pharmaceutical firm, recently released SSB 400, a generic drug manufactured from Sofosbuvir, an antiviral developed by US firm Gilead that targets hepatitis C.

Released in December 2015, the drug’s availability means Moroccans are now able to access the entire 12-week treatment for as little as Dh9000 (€825), down significantly from the original form, which costs up to Dh800,000 (€73,400). More recently, in March 2016 the firm launched two complementary drugs, Dakasvir and Ribavir, which if combined with the Sofosbuvir molecule raise the chances of recovering from hepatitis C to 95%. Like SSB 400, both drugs are made available to Moroccan patients at affordable prices: Dh1549 (€142) for Dakasvir and Dh900 (€82.52) for Ribavir.

Chronic Diseases

An even greater priority for the sector is non-communicable diseases. According to a recent study conducted by the Ministry of Health (Ministère de la Santé, MS) and the WHO, non-communicable diseases account for 75% of deaths, such as cardiovascular diseases (34%), diabetes (12%) and cancer (11%).

Improved longevity – with life expectancy increasing from an average 49.3 years in 1962 to 70.6 in 2012 – and changes in lifestyle and eating habits have meant that such diseases have been on the rise in the past few decades, claiming today three out of every four deaths in Morocco.

Various initiatives therefore continue to be rolled out in a bid to counter the spread of such diseases. For example, the Lalla Salma Foundation helped to establish the country’s first Cancer Research Institute in Fez in March 2016, in collaboration with the ministries of health and higher education. The Dh15m (€1.4m) project is located within the premises of the university hospital of Hassan II and aims at supporting and promoting research on cancer in Morocco. Similarly, in June 2015, Morocco launched a Dh15m (€1.4m) awareness campaign to promote healthier lifestyles and bring people’s attention to the implications of diabetes, which afflicts around 10% of adults aged 25 and over.

National Coverage

Achieving universal health coverage to ensure better access to health care services and medicine has been a lingering challenge the country has sought to overcome in the past decade. It has nonetheless made significant progress in absorbing a majority of the population under various state-instituted schemes.

Today, the national health coverage system in Morocco is shared between two main state-financed schemes: the Mandatory Health Insurance Plan (Assurance Maladie Obligatoire, AMO) and the Medical Assistance Regime (Régime d’Assistance Médicale, RAMED). Combined, these two schemes provide coverage to around 62% of the Moroccan population, up from 33.7% in 2010.

AMO

In place since 2005, AMO was until recently an employer-based health insurance. Benefitting up to 34% of the Moroccan population, employees in both the private and public sectors were the main beneficiaries of the programme. However, in September 2015, coverage was extended to post-secondary students, adding some 260,000 people to the pool of beneficiaries, with additional financing coming primarily from the government, which is expected to channel up to Dh100m (€9.2m) into the scheme for its latest members.

While free for students enrolled in the public sector, those studying in the private sector will need to contribute Dh400 (€36.70) annually to become eligible for the advantages offered by AMO, which include partial and total coverage on medical consultations, hospitalisation, surgery and dental care, among others. Up to 70% of the price of medicines will also be reimbursed.

A bill was presented to Parliament in March 2016 to extend the AMO to family members of existing beneficiaries. As it currently stands, AMO provides coverage to the spouse and children of the insured. Demands, however, are being made to extend entitlement beyond this sphere to include family members who are under the direct responsibility of the insured, such as siblings and parents.

Around 40% of the population – roughly 10m12m people – are uninsured, and the road ahead for expanding coverage still looks challenging (see analysis). This category consists mainly of independent, self-employed workers, such as doctors, lawyers and architects, and those in the informal sector. The debate over health insurance for independent workers, modelled on the AMO, is ongoing; as of autumn 2016 there was no clear indication as to when such a scheme might be in place.

RAMED

RAMED was first launched as a pilot project in 2009 in the region of Beni Mellal, before being expanded in 2012 to the rest of the country. The scheme, which targets the low-income population, took off with the aim of bringing health care coverage to 8.5m people, or 28% of Morocco’s inhabitants. As of December 2015, the number of RAMED beneficiaries was 9.2m people, exceeding its initial target. While this suggests that more people than originally planned are able to access health services at affordable rates, it also means that more financing will need to be sourced in order to fund the scheme.

RAMED is largely funded by the Ministry of Health, which in 2016 allocated Dh1bn (€91.7m) to the programme. Beneficiaries are also subjected to an annual contribution of Dh120 (€11) per person or Dh600 (€55) per household. However, failing to supply these funds, an estimated 700,000 existing members are struggling to contribute their share, according to recent local media reports, threatening the expansion of the scheme and straining financing capacities.

To improve this, a number of proposals are currently being examined to bring about better financial management. Suggestions include the possibility of shifting the management of the scheme from the National Agency of Health Insurance to another governing body.

Another challenge is ensuring that health services covered by RAMED are accessible, particularly in rural areas where infrastructure and medical personnel may be lacking. “Medical coverage has progressed positively in recent years. The issue now though is the additional workload expanded coverage has brought with it, considering the shortage of medical professionals, and its risks and impact on the quality of services being delivered,” Mohammed Hamouiyi, former head of the emergency department at the MS, told OBG.

An estimated 45% of doctors operate in either Rabat or Casablanca, while the proportion of doctors working in the rural parts of the country accounts for just 24%. To address this situation, authorities are looking to introduce a National Health Service (Service National Sanitaire, SNS) by which medical students would be assigned for a period of two years following graduation to designated regions nationwide. Should the SNS bill go through, doctors assigned to rural and disadvantaged areas would receive additional compensation to complement their salaries.

The idea has met with some controversy, prompting protests from students – who wanted to reserve the right to choose where they practice – at the start of the academic year. Talks with the ministry have stalled since November 2015, when possible amendments to the existing proposal were suggested, and as of September 2016 the dispute had yet to be settled.

Infrastructure

Today, public health infrastructure in Morocco is made up of 2689 primary care units and 144 hospitals, accounting for over 22,100 beds. The private sector comprises an additional 6763 surgical centres and 439 clinics, located mostly in urban centres like Casablanca, Rabat and Marrakech.

In line with increased demand for health services, Morocco is looking to overhaul existing facilities as well as invest in new ones. For instance, the country is looking to add five new university hospitals (Centres Hospitalier Universitaire, CHUs) to its current establishments in Rabat, Casablanca, Fez, Oujda and Marrakech over the next few years.

The new CHU facilities in Tangiers, Agadir, Rabat, Laayoune and Beni Mellal are expected to add up to 3200 beds and require an investment of up to Dh11bn (€1bn). Completion dates have yet to be announced. “Important efforts have been made to develop the country’s CHU network and create institutions which will allow to train medical staff in regions that lack universities such as Agadir and Tangiers,” Yves Souteyrand, the WHO representative in Morocco, told OBG.

Recent years also saw considerable effort geared towards upgrading and bolstering emergency services in a bid to ensure better urgent care. According to figures from the Ministry of Health, between 2012 and 2014 alone Morocco acquired 226 ambulances, deployed three medical helicopters in Marrakech, Oujda and Laayoune and established 40 new emergency units around the country. Recently refurbished departments include the emergency unit at the Ibn Sina hospital in Rabat, which was delivered in July 2015.

A number of mobile health centres have also been created to help bring services closer to patients residing in remote parts of the country. As of December 2015, 58 units had been created and an additional 20 were in the pipeline. These mobile units offer a variety of services from medical consultation to screening and surgery.

Health infrastructure is also expanding in the private sector. Among the latest newcomers is the Sheikh Khalifa bin Zayed Al Nahyan hospital in Casablanca, opened in March 2015. The $100m project was developed as a public-private partnership (PPP) between the UAE’s Khalifa bin Zayed Al Nahyan Foundation and the Moroccan government. Extending over an area of 65,000 sq metres, the new hospital offers a bed capacity of 280 beds. As of end 2015, the hospital had already treated some 30,000 patients.

Privatising Care 

Private health care in Morocco has experienced some important changes in recent years, perhaps the most prominent of which is the 2014 reform granting investors, and not exclusively doctors, the right to establish private clinics. This move came on the back of evolving and rising demand for health care services, as well as limited capacity for the public sector to unilaterally meet these needs. The ultimate goal of the reform is to increase the number of health facilities across the country, thereby stimulating competition, promoting PPPs and ensuring access to quality health services.

Among the first investors to take advantage of this new opportunity was local insurance firm Saham Group, which has since acquired a handful of health facilities. These include Clinique Ghandi in Casablanca and the Mediterranean Centre for Cancer in Tangiers, as well as a stake in Casablanca’s Clinique Yasmine. The group is also investing in a new 200-bed hospital in Marrakech, expected to be completed in 2016.

Foreign investors have also come in to grab a share of the pie. In 2015 UAE-based Abraaj Group purchased majority stakes in two Moroccan private clinics, Al Kindy in Casablanca and Menara clinic in Marrakech, both entirely dedicated to oncology. Tasweek, another Emirati group, also announced its plans to invest Dh30bn (€2.8bn) in the medical tourism segment, including Marrakech Healthcare City, a $40m clinic and hotel complex currently under construction with a patient capacity of 5000. The firm has outlined similar projects for Tangiers, Agadir and Casablanca.

Medical Staff Shortage

Human resources represent one of the weaker links in Morocco’s health care system, which suffers from a shortage of medical staff and disproportionate geographical distribution, in the face of rising demand. The dearth of personnel has been attributed to a variety of causes, including an insufficient replacement rate – the number of employees working under the auspices of the Ministry of Health who reach retirement age is approximately 1500 departures each year – as well as lower numbers of new graduates, the lengthy durations of course work and outdated training methods.

In 2012 Morocco had 0.62 doctors for every 1000 inhabitants. Its target, however, is to reach one doctor for every 1000 inhabitants by 2020. To that end, under Vision 2020, the government has set itself the target of training 3300 doctors every year. However, with its current 900 doctors graduating annually from Morocco’s five public medical universities, the country still has some headway to make before it can meet its objective.

New schools to support the government’s ambitions to upgrade the sector’s human resources include the much-anticipated teaching facilities in Agadir and Tangiers. According to local media reports, works on Agadir’s medical school were 85% completed as of January 2016. Estimated at Dh315m (€28.9m) and financed by the Saudi Development Fund, the school should see its doors open on time for the 2017-18 academic year and have a student capacity of 4500.

On average, the number of doctors has increased by 4.7% annually since 2004. However, skilled staff positions elsewhere in the sector have fared worse: the number of nurses has progressed at a lower pace, growing by just 1.9% since 2004. While public training institutions have put approximately 3000 graduates in health-related professions such as nursing, obstetrics and midwifery on the market each year since 2013, their numbers still remain shy of their potential.

In a bid to make this sector more attractive, the country’s 23 public training institutions benefitted from a reform plan launched in 2014 that rebranded the previous Public Institution for Health Professions as the Higher Institute for Nursing and Health Techniques, at which post-graduate courses now available and the first masters programme is expected to start in 2017.

Outlook

Broader health coverage and the gradual expansion of medical services bode well for the future of Morocco’s health care sector. The challenge that lies ahead, however, is to ensure even distribution of facilities and medical staff as demand for health services rises. An estimated 20% of the population lives more than 10 km away from a primary care centre. Lingering disparities between urban and rural populations will continue to hold back health indicators from evolving more rapidly if not effectively addressed, particularly in terms of maternal and child health care.

The cost of health care is another matter that requires further scrutiny. Household spending on health in Morocco remains high, with spending per capita in 2013 amounting to $195, driven largely by the high cost of medicine. It is likely to take some time before the impact on spending and consumption of the government’s medicine price reduction policy, introduced in 2013, becomes apparent. “Medicine costs have been reduced but achieving objectives is a ways off because prices still remain relatively high and generic drug consumption insufficient,” the WHO’s Souteyrand told OBG.