Enhancing provision: Focusing on expanding health care access and improving infrastructure

Galvanised by encouraging policy-driven results, as well as by the 2011 constitutional amendments that enshrined access to health care as a basic right of all citizens, Morocco is securing the gains it has made over the past two decades. The government is hoping a regional approach to health care management will help improve governance and reduce the disparity in health care provision between urban and rural areas.

PATTERNS: In many ways, the challenges the country faces today are related to its economic development. Maternity rates have gone down, from around 7.7 children per woman in the 1970s to about 2.2 per woman today. Stabilising population growth and increased living standards have been reflected in a steep reduction in the prevalence of infectious diseases and the growth of chronic ones. As more money is spent on new hospitals, the country continues to face a shortage of doctors. A state health insurance scheme is making health accessible to the country’s poor. Overall governance of sector components has become a top priority.

With efforts to push effectively for regionalisation at all levels of government, the health sector is embarking on a process that the government hopes will eventually result in more autonomy for regional and local health management. Targeted approaches for health policies at the regional level will encourage more efficient use of materials and human resources.

INDICATORS: According to the World Health Organisation, total expenditure on health per capita in Morocco reached $246 in 2010. On the other hand, World Bank figures show total expenditure as a percentage of GDP rose to from 4% of GDP in 1999 to 5.2% of GDP by 2010. Most of this is still private spending, although the government has certainly increased the level of public health expenditure, which rose from 32.8% in 2006 to 38% in 2010. The national budget for health has also been on the rise, increasing from Dh5.4bn (€480.1m) in 2004 to Dh11.4bn (€1.01bn) in 2011.

Infant health has seen improvement over the years, with an important reduction in several indicators. Child mortality has seen a 64% reduction between 1992 and 2011, from 84 deaths per 1000 births, to 30.2 deaths per 1000 births. Women’s health remains a worry though. Despite the fact that the country was able to reduce maternal mortality by 66% in the two decades from 1992 to 2010, from 332 maternal deaths for 100,000 births to 112 maternal deaths per 100,000 births in 2010, Ministry of Health figures show it is twice as high in rural areas – there are 148 deaths per 100,000 births in rural areas, as opposed to 73 deaths per 100,000 in urban areas. These indicators indicate the discrepancy in health provision for different regions.

DISEASE PATTERNS: Strong implementation of vaccination campaigns, coupled with better sanitation in rural areas, have helped the country deal with the spread of infectious diseases. Some problems persist though. Tuberculosis is a challenge, with government figures from 2012 noting 28,000 new infections a year, 70% of which are in urban areas. This has prompted the state to start work on a new tuberculosis strategy.

Efforts at HIV prevention and treatment have also gained new momentum. The spread of the virus has largely been kept at bay, with current incidence levels for the general population at 0.15%. Morocco was one of the first Arab countries to implement policies targeting drug addicts, such as syringe exchange programmes and methadone maintenance therapy.

The government has, nonetheless, been paying close attention to some pockets where higher levels of infection among specific population groups could propel a more worrying prevalence in the future. Ministry of Health estimates show that around 5% of sex workers in Agadir, a major tourist spot, are HIV-positive. In Nador, a coastal area on the Mediterranean, one in five drug addicts that use needle injections are infected with the virus. This has prompted government officials to establish a new AIDS strategy, focused on increasing the number of treatment centres and putting more effort towards prevention. The goal is to reach a 60% reduction in AIDS-related deaths by 2016. There are 13 AIDS treatment centres across the country, providing retroviral medicine to about 5000 patients. Four more treatment centres are due to open in 2013.

CHRONIC ILLNESSES: Rising awareness about chronic illnesses has put focus on lifestyle-related health problems, especially after a 2012 government study of health patterns in Moroccan families. The study, which is done every five years by the Ministry of Health, showed an alarming increase in the prevalence of diseases like high-blood pressure, diabetes or cancer.

The number of Moroccans living with chronic ailments has increased from 13.8% in 2004, to 18.2% in 2011. During the same period, the percentage of people suffering from diabetes has increased from 1.6% to 3.3%. More worryingly was the rise in the number of cases of arterial hypertension, which affected 2% of the population in 2004 and 5.5% seven years later.

Another chronic illness affecting the population is cancer, especially given that thee national smoking prevalence of 15% among those over 15 years old and that 90% of lung cancer is due to smoking. The creation of the Lalla Salma Association Against Cancer in 2005 has set up a national plan to fight cancer with the application of best clinical practices and raising awareness.

GOVERNMENT STRATEGY: In 2012 the Ministry of Health launched its 2012-16 action plan. Following on the path of previous strategic orientations, the government is putting effort towards reducing infant mortality further, increasing child health and improving the conditions in which Moroccan mothers give birth. Part of this effort will depend on increasing the amount of births that happen with medical support, from the current figure of 73% to 90% by 2016. This is especially important in rural areas, where more than half of births happen without supervised medical attention. Further emphasis will be put on infant medical support.

Mental health is also gaining more attention and is to be an important element of reform over the coming years. The first step will be to deal with the shortage of qualified doctors. A programme for training mental health professionals is to be put in place in 2013 with the goal of training 30 psychiatrists and 185 specialised nurses per year. This will be mainly done through the opening of new psychiatric departments in at least four universities across the kingdom, to focus on child and adolescent psychiatry. Capacity in psychiatric hospitals is to be increased as well, with the government planning to raise the number of available beds from 800 in 2012 to 3000 by 2016.

Regionalisation will also encourage a community-based policy on hospital and pre-hospital emergency care, especially in rural areas. The Ministry of Health recently announced plans to open a total of 80 emergency medical facilities away from big urban centres. The plan is to increase the yearly number of Moroccans treated in emergency centres from the current 4m to 6m in the coming years. The move to expand emergency health support in rural areas has already been reflected in the opening of 20 emergency medical units for rural obstetrics in late 2012, as well as the acquisition of 55 ambulances and 6 mobile hospitals.

INFRASTRUCTURE: Boasting 147 public hospitals with a bed capacity of 27,325, and 2698 basic health centres, Morocco has been expanding health care infrastructure, especially in rural areas. Besides an ongoing programme to build more than 30 new hospitals across the country before 2014, the government has also been focusing on revamping existing infrastructure and equipment. Under the Maroc Santé III plan, which was partially financed by the European Investment Bank, major renovation work is under way in 17 public hospitals and health centres, including the cities of Temara, El Jadida, Salé Larache, Khenitra, Tanger, Essaouira, Ouarzazate and Chefchaouen. Increased financing is also being directed at equipment maintenance. From Dh45m (€4m) in 2008, the budget for hospital equipment maintenance has almost quadrupled to Dh161m (€14.3m) in 2012, a needed increase as the number of public hospitals continues to rise.

An endemic shortage of available doctors and nurses has also proved to be a pressing challenge while trying to increase care. “If the Ministry of Health puts out an ad for 100 doctors, we probably only get about 80,” Hassan Semlali, the division chief in charge of RAMED at the Ministry of Health, told OBG. “There are simply not enough doctors available.” According to ministry figures, in 2012 Morocco had six doctors and nine nurses per 10,000 people. Density is higher in cities: the capital, Rabat, has 20.3 doctors per 10,000 people and Casablanca has 16.1 doctors per 10,000 people.

Increased autonomy for regional health directors will allow local powers to redeploy human resources within regions. But the hiring of doctors for public institutions is still centralised in Rabat. Beyond governance issues, the real challenge will be to increase the number of doctors and nurses, especially when some trained health professionals opt to work in Europe. The Ministry of Health hopes new training programmes will increase the number of new doctors joining the workforce to 3300 a year. It aims to bring the national ratio up to 10 doctors per 10,000 people by 2020. But besides training new doctors, the expansion of the sector’s workforce will depend heavily on the state’s financial capacity to hire new professionals.

INSURANCE: With the full implementation of the medical assistance regime (Régime d’Assistance Medicale, RAMED) taking place in 2013, around 8.5m uninsured Moroccans will begin to get access to the country’s public health network (see analysis). This will be an important addition to increase health coverage.

The employer-based basic state health insurance firm Assurance Maladie Obligatoire (AMO), managed by the National Health Insurance Agency, has been mandatory since 2005, but some issues remain with regards to the pricing levels established under the AMO, which do not cover full reimbursement for certain health procedures and treatments.

This is especially relevant for complicated medical operations such as neurosurgery or cardiac procedures, which tend to be procured from private clinics.

WORKING WITH THE PRIVATE SECTOR: There are over 300 private clinics with a bed capacity of about 5500, most of them based in Casablanca, Rabat and other major cities. Despite some medium-sized structures with 50 to 100 beds, most of the private sector is made up of small clinics with an average capacity of 30 beds. Although private health operators make up an important part of the country’s overall health offer, especially in urban areas, the government has been increasingly adamant about enforcing standards. The government closed down 13 private clinics in 2011, due to insufficient quality of equipment and potential health safety issues, and it has been keeping up with inspections on private health providers across the country.

However, with more foreign private investment into the health sector, the country’s network of private clinics might prove attractive to European companies wanting to expand on the kingdom’s existing know-how in health care provision. Private clinics are considered to be a faster and efficient alternative to the government-led public health care services and are increasingly chosen by those who can afford them. As well, public-private partnerships are already operational in the area of chronic renal failure.

PHARMACEUTICALS: The kingdom’s pharmaceuticals sector has been through steady growth over several decades, with the number of local and foreign manufacturing units growing from 13 facilities in 1975 to 32 in 2011, according to the Moroccan Association for the Pharmaceutical Industry. Sales of pharmaceuticals reached Dh8.5bn (€755.7m) in 2012, a 4% increase on 2011 figures, said Abdelghani El Guermai, the association’s president. Production accounts for 70% of local consumption, but despite being the second most important pharmaceutical market on the continent after South Africa, exports are still low compared to existing capabilities, at 10% of annual production.

Efforts have been put on expanding the use of generics, which now account for 40% to 50% of the market. Minister of Health Houssaine Louardi announced immediate price reductions for 320 pharmaceuticals in November 2012. The decision was reached after talks between the government and industry bodies. The reductions, which go as far as 50%, will focus mainly on drugs used for the treatment of chronic problems such as cancer and cardiovascular diseases, which are not only expensive, but lack a generic equivalent. These price decreases come on the back of earlier 2010 government-led cuts, which saw reductions in 260 drugs.

OUTLOOK: The 2011 constitutional amendments have showcased governmental efforts to improve health provision and will serve as a base to develop future policy. But the pressing issue of human resources will define the way in which the government can effectively expand delivery, and reduce differences between rural and urban areas. Although the RAMED insurance scheme will greatly improve the number of people who have access to medical attention, future success will depend on revamping existing infrastructure and deploying new equipment into less developed areas. Region-alisation will also help to better manage resources.