High health budget in Morocco drives investment in pharmaceuticals and private health facilities

Morocco has made steady progress on Santé 2025, the quadrennial national strategy for improvement of the country’s health care sector. The kingdom recently inaugurated a number of new public health facilities and is approaching universal health coverage as it extends insurance schemes to self-employed workers and other segments of the population. The private sector has also made significant investments in new clinics and pharmaceutical production units. Moreover, the kingdom continues to be an attractive destination for medical tourists, who come from sub-Saharan Africa in increasing numbers. At the same time, however, the sector faces serious challenges, most notably those related to a shortage of human resources in the public sector and the prevalence of non-communicable diseases (NCDs).

Structure & Oversight

The Ministry of Health (MoH) oversees the sector and manages the kingdom’s public health facilities, including state hospitals. The ministry is also responsible for the implementation of health policies such as Santé 2025.

According to the Ministry of Economy and Finance, in 2020 the MoH had an operating budget of Dh15.3bn ($1.6bn), up from approximately Dh13.2bn ($1.4bn) in 2019. Beyond the MoH’s operating budget, the 2020 Finance Law allocated the ministry an additional Dh3.4bn ($354m) for investments associated with the implementation of Santé 2025. In 2020 the government allocated some Dh91bn ($9.5bn) to health, education and scientific research, with spending on health care comprising roughly Dh18.7bn ($1.9bn) of the total. The decision to focus on health and education is in line with the vision laid out by King Mohammed VI in a July 2018 speech, in which he called for urgent action to address the kingdom’s inequalities.

The private sector accounts for the majority of health care spending in the kingdom, at 52.5% of the total in 2016, according to the World Bank. Doctors in the private sector constitute a majority of doctors/ health care professionals. According to state planning and statistics body the High Planning Commission (Haut Commissariat au Plan), of the 23,300 doctors working in the kingdom in 2017, some 12,400 were employed in the private sector and 10,900 in the public sector. In addition, non-governmental organisations – such as the Lalla Salma Foundation for the Prevention and Treatment of Cancer, which has undertaken efforts to improve cancer treatment and awareness – also play a prominent role in the sector.

General Indicators

According to World Bank estimates, since 2000 the kingdom’s key health indicators have gradually improved. For example, in 2017 average life expectancy at birth stood at 76.2, up from 68.7 in 2000. Women are expected to live up to 77, slightly longer than men, who are expected to live to around 74. In neighbouring Algeria and Tunisia, average life expectancy was 70.6 and 73.2, respectively, in the same year. Moroccans also live longer than the average person in the MENA region (73.9).

Maternal and infant mortality rates have similarly improved since 2000, with the maternal mortality rate falling to 70 per 100,000 live births in 2017, down from 188 in 2000. While the rate is lower than in Algeria (112), it is higher than in Tunisia (43) and the MENA region overall (57). The infant mortality rate stood at 19.2 per 100,000 live births in 2018, down from 41.7 in 2000. In MENA, Tunisia and Algeria, the average rates were 18.3, 14.6 and 20.1, respectively.

Disease Burden

As in many other high- and middle-income countries, NCDs represent the greatest threat to public health in Morocco. According to the World Health Organisation (WHO), NCDs were responsible for 80% of all deaths in 2016. The most prevalent was cardiovascular disease, which was responsible for 38% of all deaths, followed by cancer (14%), chronic respiratory diseases (4%), diabetes (6%) and other NCDs that collectively accounted for 18%. Throughout the MENA region as a whole, NCDs were responsible for roughly 74.5% of all deaths. While the rise in deaths associated with NCDs can be partially attributed to positive changes like longer life expectancies and lower instances of communicable diseases, lifestyle-related choices such as tobacco use and poor diet also contribute to the growing numbers.

In February 2019 the MoH unveiled a Dh5.4bn ($563m) national strategy to address and prevent NCDs. The strategy, prepared in partnership with the WHO, sets a number of targets to be completed by 2029. One of the main objectives of the strategy is to promote healthier lifestyles by establishing goals such as a 20% reduction of tobacco consumption and a 10% decline in overall salt consumption. To achieve these goals, the strategy indicates a need for greater ongoing efforts to educate the public about NCDs and healthy lifestyle habits. It also calls for the consolidation of health care services aimed at disease prevention. The strategy aims to reduce premature deaths caused by NCDs by 25% by 2029.

Although NCDs are the leading cause of death in Morocco, a number of communicable diseases remain a concern. For example, in 2017 there were around 99 cases of tuberculosis per 100,000 people, representing an improvement from roughly 115 cases per 100,000 in 2000, according to WHO estimates. Throughout the MENA region, the average incidence of tuberculosis is 31 per 100,000 people.

In 2016 around 14% of deaths in Morocco were the result of communicable, maternal, perinatal and nutritional conditions. In March 2019 then minister of health Anas Doukkali said that the ministry considered the treatment of tuberculosis a high priority and aimed to reduce associated deaths by 40% by 2021.

Private Sector

According to a 2018 MoH study on population and family health, in 2017 there were 333 private for-profit and 23 private non-profit clinics, with combined bed capacities of 8554 and 1165, respectively. While private medical facilities provide a smaller share of medical services in the kingdom, these clinics can be more attractive than public facilities to both patients and doctors. Although roughly 1500 more doctors work in the public sector, private clinics make up a minority of the kingdom’s total bed capacity.

Following 2015 legislation allowing individuals – other than doctors – to own private clinics, private medical infrastructure has expanded rapidly, particularly throughout major cities such as Casablanca, Rabat, Tangier and Marrakech. Between July 2018 and October 2019 Moroccan clinic operator Akdital Holding opened four new clinics in the Casablanca area: two multidisciplinary clinics, an oncology clinic and a cardiology clinic. Meanwhile, a number of other private operators have pursued a strategy of consolidation. In mid-2019 Oncologie et Diagnostic du Maroc acquired Clinique Badr in Casablanca, and KMR Holding acquired the Hôpital Privé de Marrakech 2018.

One of the private health sector’s main drivers of growth is demand from medical tourists. The most well-established segment in terms of regularly attracting medical tourists is plastic surgery. Tourists from Western Europe and the Middle East comprise many of the foreign patients in local clinics. However, patients from sub-Saharan Africa – in particular from countries such as Côte d’Ivoire and Senegal – are increasingly common. The most sought-after procedures for medical tourists include eyelid surgery, rhinoplasty and face-lifts. In addition to plastic surgery, medical tourists routinely travel to Morocco to receive treatment related orthopaedics, oncology and ophthalmology.

Public Sector

In 2017 there were 158 public hospitals located in the kingdom. Of these, 25 were university hospitals, 26 were regional, 77 were provincial or prefectural, and 30 were local, with a combined bed capacity of 25,380. A key priority of Santé 25 is to develop the kingdom’s public hospital network. In 2018 some 13 new hospitals were built, with a combined bed capacity of 1085. These include provincial hospitals in Temara and Driouch, as well as local hospitals in Imzouren and Ksar El Kebir.

Construction has begun on five health care facilities, including a university hospital centre in Laâyoune. According to the Ranking Web of World Hospitals – an initiative from Cybermetrics Lab, a research group of the Spanish National Research Council – the best performing hospitals in Morocco are the publicly funded Centre Hospitalier Mohammed VI in Marrakech and the Centre Hospitalier Universitaire Ibn Rochd Casablanca, which rank 3133rd and 5189th, respectively.

Medical Staff

The shortage of human resources is one of the main challenges facing Morocco’s public health system. In 2017 there were 4284 patients for every doctor in the public sector, while the figure was notably lower, at 2888, in the private sector. The shortage of doctors and relatively low compensation have led to widespread dissatisfaction among doctors and other health care professionals. In August 2019 doctors participated in a two-week strike organised by the Independent Union of Public Sector Doctors. Earlier that year around 300 doctors in northern Morocco collectively resigned in protest of the public health system’s shortcomings. However, some progress has recently been made, and in Budget Citoyen 2020, a consumer report on the 2020 budget, the government noted that the number of patients per doctor fell from 1600 in 2011 to 1386 in 2018.

Insurance

In August 2019 the government adopted a decree that expands coverage under Compulsory Health Insurance (Assurance Maladie Obligatoire, AMO), one of the kingdom’s two main public health insurance schemes. The AMO was launched in 2005 with the purpose of providing coverage to those employed in the government and private sectors, as well as their dependants. Through the new plan, patients are eligible to be reimbursed for up to 70% of the cost of their private health care treatment and 80% of their public treatment.

The new decree extends AMO coverage to professionals, self-employed workers and those in liberal professions who do not receive a salary. Those who work in various medical, legal and financial fields are expected to benefit most from the coverage. Once the decree is implemented, 11m insured persons will benefit from medical coverage. According to the latest social security report by the Supervisory Authority of Insurance and Social Security, as of end of 2017 some 9m Moroccans were insured by the AMO. In addition, the MoH announced in December 2019 that children aged five and younger, who are not eligible for the AMO, may receive free cancer treatment.

The Medical Assistance Regime (Régime d’ Assistance Médicale, RAMED), which was launched in 2009 to provide medical coverage for people with lower incomes, is the kingdom’s other main health insurance scheme. As of September 2019 around 14.4m citizens were covered by RAMED. Members of the Moroccan armed forces are covered by a third government-backed scheme.

Pharmaceuticals

In 2018 the value of the local pharmaceutical market was approximately Dh16.53bn ($1.7bn), and it is forecast to reach Dh33.76bn ($3.5bn) by 2029. According to the Moroccan Association for the Pharmaceuticals Industry (Association Marocaine de l’Industrie Pharmaceutique, AMIP), in October 2019 sales of generic drugs were up 9.7% from the previous year, constituting approximately 40% of the local pharmaceutical market by volume and value. Sales of brand-name drugs grew by 1.9% in volume and 5.5% in value over the same period.

A number of recent regulatory changes are expected to expand the kingdom’s market share of generics, and in turn, decrease the price of drugs. There is strong sentiment among industry stakeholders that pharmaceutical companies need to diversify their cost advantages, and find the proper balance between the quality consumers demand, and the prices they are willing and able to pay for.

In March 2019 the government issued a new decree requiring pharmaceutical companies to demonstrate a generic drug’s bioequivalence to a corresponding brand-name drug, prior to obtaining authorisation to sell the generic version. “The decree is likely to boost the market share of generics in the local pharmaceutical market,” Layla Sentissi, executive director of AMIP, told OBG. “In the short term, pharmaceutical companies that wish to commercialise generic drugs will need to commission bioequivalence studies. In the long term, however, physicians are more likely to prescribe generic drugs, since they are more affordable and studies document their bioequivalence to brand-name drugs,” she said.

Sentissi also noted that the market share of generic drugs in Morocco (40% in 2019) is considerably lower than that in markets such as the US, where the market share of generic drugs is approximately 89%. This difference indicates that the kingdom has the potential to significantly reduce overall health costs by continuing to expand the use of generics. “Although bioequivalence studies are now mandatory, high-quality generic drugs have been commercialised in Morocco for decades,” Sentissi added.

As of early 2020 bioequivalence studies were mandatory for generic drugs. The new decree seeks to ensure that generic drugs are equally as safe and effective as their brand-name counterparts. Companies currently commercialising generic drugs will be required to submit proof of bioequivalence with their applications for renewed marketing authorisation, which are required every five years. As part of the national drug policy aimed at facilitating access to drugs and reducing health care costs, in February 2019 the MoH announced that the government had lowered the prices of 319 drugs after exempting them from the kingdom’s value-added tax. The price decreases followed provisions in the 2019 budget that exempted drugs with public selling prices of over Dh962 ($100). The drugs in question are primarily medications such antibiotics and treatments for anaemia, haemorrhages, epilepsy, sclerosis and polyarthritis. The MoH has reduced the average price of over 3700 medications since 2014, when it began the implementation of Decree No. 2.13.852, which concerned the overall regulation of drug prices.

Another key aspect of the MoH’s drug policy is ensuring that drug costs in Morocco match international benchmarks. According to the new decree, the MoH may lower prices if local drug prices exceed international benchmarks, and pharmaceutical companies may request to commercialise drugs at higher prices if local prices are below these benchmarks.

Although the majority of revisions since 2014 have involved price cuts, in April 2019 the MoH increased the prices of 14 drugs. The increases in the public selling prices for the drugs ranged from Dh2 ($0.20) to Dh150 ($15.63), and included brand-name medications such as those used to treat cancer, epilepsy and cardiovascular issues. Sintrom, a medication used to prevent blood clots, saw the lowest increase, from Dh17.90 ($1.87) and Dh20 ($2.08). Protamine Choay, meanwhile, a medication that is most commonly used during heart surgery, was subject to the highest increase, from Dh16.10 ($1.68) to Dh166 ($17.32).

Sentissi welcomed the price revisions, telling OBG that such repricing helps pharmaceutical companies maintain a sustainable business model in the local market because they “incentivise local production and investment, which will help reverse the kingdom’s reliance on pharmaceutical imports”.

Throughout 2019 a number of pharmaceutical companies in Morocco announced the opening of new production units and investments which are set to further boost local production capacity – a key factor in meeting the goals set by Santé 25 and the Industrial Acceleration Plan (see Industry & Mining chapter).

In June 2019 Mylan Pharmaceuticals Maroc, a subsidiary of US-based pharmaceutical company Mylan NV, announced the inauguration of the company’s first production unit in the country. Mylan intends to invest approximately Dh120m ($12.5m) in its local production facilities by 2023. The company also has plans to manufacture drugs such as MyhepAll, a generic medication for the treatment of hepatitis C. As of early 2020 its facilities covered 1500 sq metres, and plans were in the pipeline to expand by around another 900 sq metres. Meanwhile, in January 2019 Moroccan pharmaceutical company Sothema inaugurated a new Dh200m ($20.8m) manufacturing facility, intended to produce a number of anti-cancer drugs. The facility, which is based in Bouskoura, 20 km south of Casablanca, will manufacture cancer treatments based on biosimilars, which are expected to be around 30% cheaper than those currently used. Notably, this facility is among the first in Africa to produce anti-cancer drugs that focus on biotechnological techniques.

Outlook

Morocco’s growing insured population and middle class is likely to incentivise additional investment in private health facilities and pharmaceutical production units. At the same time, the government has demonstrated progress in meeting goals set by Santé 25, which is likely to continue given the increase in the MoH’s budget in 2020. However, the public health sector will likely continue to face pressure to address the ongoing shortage of health professionals.