Increasing coverage: Developments and persisting challenges in the push towards universal health care

In the wake of the Arab Spring, Moroccan citizens approved a new constitution by a landslide vote in July 2011. This promised a range of new rights, including universal health care and access to quality health services. The authorities have since taken a number of steps to increase coverage, reduce costs, improve service quality, and extend services in rural and otherwise isolated areas.

However, despite significant progress in recent years, a number of critical challenges remain, including chronic staff shortages, particularly in the public health system; disparity in service quality; lack of financial resources; gaps in governance, especially regarding efforts to decentralise control of the public health system; and additional issues created by the burgeoning private segment.

In response to these continuing challenges, in May 2017 the Ministry of Health introduced the Health Sector Strategy 2017-21, a plan to prioritise certain health goals to raise the rate and quality of coverage in Morocco. The main objectives of this strategy are to improve the capital resources that hospitals receive, from MRI machines to ambulances; expand medical coverage to include individuals who are either self-employed or in liberal arts professions; decrease the incidence of deafness, cardiovascular diseases and hepatitis C; increase the number of employees in the health sector; standardise the type of education that Moroccan medical students receive; and lower the price of pharmaceuticals, especially those that are very expensive, such as medicine for cancer and hepatitis-C treatment.

SYSTEM STRUCTURE: Approximately two-thirds of the population have medical coverage through one of two state-financed health care schemes: the Mandatory Health Insurance Plan (Assurance Maladie Obligatoire, AMO) or the Medical Assistance Regime (Régime d’Assistance Médicale, RAMED). AMO was introduced in 2005 and began as an employer-based health insurance programme. It continues to provide health coverage to employees in the public and private sectors, but has expanded to include post-secondary students and family members of beneficiaries. Approximately 34% of the populace receives health insurance through AMO, and the government provides around Dh100m (€9.3m) per year in funding for the scheme.

RAMED was later launched as a pilot programme in 2009 for the purpose of providing health care to citizens of low socio-economic status. After initial success, RAMED has expanded to cover all regions of the country, and by December 2015 it had already exceeded its goal of insuring 30% of the population. RAMED is primarily financed through tax revenue, with the government allocating around Dh1bn (€92.6m) annually to the measure. A further small but growing share of Moroccans are covered by private health insurance. These individuals pay out of pocket when they use public health facilities and are later reimbursed by their insurer.

Despite significant progress towards the goal of universal health care, approximately one-third of the population remain uncovered by any type of medical insurance. While all vaccines and some treatments, such as those for tuberculosis and malaria, are offered free-of-charge to citizens, out-of-pocket fees are charged for the majority of procedures that entail going to a hospital.

EPIDEMIOLOGICAL TRANSITION: Due to demographic shifts and the country’s success in eradicating certain communicable diseases, Morocco has been undergoing an epidemiological transition. This is characterised by an increasing rate of non-communicable afflictions – such as cancer, heart disease and diabetes – and the declining rate of communicable diseases such as malaria, polio and tetanus. In 2000, 22.9% of all deaths in Morocco were caused by communicable diseases or maternal, prenatal and nutrition conditions. By 2015 this number fell to 15.4%, according to the World Bank. Meanwhile, the share of deaths caused by non-communicable afflictions increased from 67.9% to 77.8% in the same period. The widespread rollout of vaccination programmes, as well as efforts to eradicate malaria, have been key to reducing the incidence of communicable diseases.

Another area of significant progress has been the sharp decrease in maternal mortality. According to the National Survey on Population and Family Health, maternal mortality dropped from 192 per 100,000 live births in 2000 to 68.5 in 2015. Infant mortality also witnessed a decline in the 2000-15 period, from 42.2 per 1000 live births to 23.7.

The drop in maternal and infant mortality rates and the rise in deaths by non-communicable disease are key indicators of Morocco’s shifting medical priorities, with the government now working to determine how to best combat the new challenges of public health conditions.

FUNDING REQUIREMENTS: In 2005 Morocco joined the Abuja Declaration, an agreement by various countries in the African Union to increase public health spending to at least 15% of their respective national budgets. Initially, Morocco was progressing steadily towards this goal: health expenditure rose from 4.4% in 2005 to 6.6% in 2009. However, since 2009 this has slid back, and by 2015 spending on health was 5.3% of the state budget. The country not only continues to lay out less than the 15% target, but is behind its peer countries in North Africa: both Algeria and Tunisia spend at least 10% of their national budgets on health care.

While presenting the Health Sector Strategy 2017-21 in May 2017, Houcine El Ouardi, then-minister of health, noted the lack of financial resources as a critical obstacle to improving public health. The annual health budget, at approximately Dh14.3bn (€1.3bn), has changed little in recent years and accounted for just 5.7% of total public spending in 2017. This is less than half the 12% threshold the World Health Organisation (WHO) recommends for countries such as Morocco that are trying to improve their health systems. Moreover, the minister underscored that 54% of the health budget is used to pay staff salaries, meaning less than half the budget is available for investment in new facilities and equipment.

Despite the wage bill’s share of health spending, Morocco scores low in terms of physician density, with only 6.2 per 10,000 inhabitants, according to the World Bank report “Morocco 2040: Emerging by Investing in Intangible Capital”, published in early 2018. The ratio of medical personnel is below critical thresholds, with physician density around half that in neighbouring Algeria and Tunisia: underfunding is largely responsible for such insufficiencies.

Budget scarcity is also reflected in the shortage of hospital beds, at 11 per 10,000 inhabitants. This falls to one bed per 10,000 residents for mental health treatment – less than one-quarter the global average of 4.4. As of early 2018 discussions regarding fiscal strategies to increase investment in health care, potentially by closing tax loopholes or taxing inheritance, were still in progress.

STAFF SHORTAGES: One of the biggest challenges posed by underfunding of the public health system is the inability of authorities to recruit sufficient medical and administrative staff. According to El Ouardi, the 2017 budget allows the Ministry of Health just 1500 new hires for the year – significantly lower than the average of 2000 across all ministries.

The country’s demographic profile has exasperated the staffing shortfall in two ways: in terms of rising demand for health services from the population and from the age of the existing medical workforce, which has seen large waves of professionals take scheduled or early retirement in recent years. This has caused a number of much-needed medical facilities to fall into chronic underuse from not employing enough physicians, and has also increased pressure on existing staff. As a result of the persisting human resource shortages, as of mid-2017, 14 well-equipped hospitals in Morocco were lying idle.

In the face of such challenging working conditions in recent years, some medical staff in the public system have been tempted to move to the private segment. Strong demand from the US, Canada and Europe for Moroccan medical staff has also encouraged some to emigrate for employment purposes.

Personnel shortages are often unevenly distributed geographically. Medical facilities in remote areas face a more critical lack of staff than those in large cities, such as Casablanca and Rabat. Given the concentration of private health care in the North Atlantic region, staff shortages in the public system tend to exacerbate existing inequalities in provision in other parts of the country.

Yves Souteyrand, WHO representative in Morocco, told OBG, “Addressing these chronic human resource issues will require both money and patience. Increased investment will be needed to boost the headcount of medical practitioners in the public system, both to pay salaries and to ensure that working conditions are attractive enough to stem the flow of health workers from the public system to the private segment, or abroad. Given the long lead time in hiring medical staff – training can take 8-10 years – it could be some time before we see a real improvement in the situation.”

HOSPITALS & EQUIPMENT: Achieving national health outcomes and quality of care on par with advanced economies will require continued investment in cutting-edge medical facilities and technologies. Sector authorities have been making marked progress in pursuit of this goal. Late 2016 saw the announcement of a Dh90m (€8.3m), 70-bed hospital for the Laâyoune-Sakia El Hamra region in the south. As a longer-term project, the government has also allocated Dh1.2bn (€111m) for a 500-bed university hospital for the area. The government’s new Health Sector Strategy includes plans for a further 14 hospitals in the years to 2021.

Private health care providers have also been expanding medical infrastructure. In June 2017 the Evya Clinic Network opened the Hôpital Privé de Marrakech, a 171-bed facility, while Elsan, one of France’s main private hospital providers, built a new 136-bed facility at Bouskoura called Clinique Ville Verte, inaugurated in January 2018.

Among the most important recent initiatives have been efforts to increase the capacity of medical education and training programmes. To this end, King Mohammed VI ordered the construction of the Mohammed VI University of Health Sciences, worth approximately Dh600m (€55.6m). The multi-disciplinary centre consists of six training institutions for medicine, dentistry, nursing and health sciences, international public health, pharmacy and biomedical engineering. Located in Casablanca, building works began in January 2015 and the complex opened in August 2017.

In early 2017 local media reported that five Moroccan medical facilities – PharmaProcess in Casablanca, ImmCell in Rabat, Al Azhar Oncology Centre, Riad Biology Centre and Oudayas’ Medical Analysis Laboratory – joined a global network of 260 hospitals in 46 countries using SOPHiA GENETICS’ artificial intelligence in their operations. The new technology aims to identify and treat diseases using patients’ genomic profiles as part of the growing field of data-driven medicine.

This development marks a positive step in responding to the need to increase national investment in research and development (R&D). Rachid Arsala, CFO of Sheikh Khalifa Bin Zayed Al Nahyan Hospital, told OBG, “R&D is a missing link in Morocco. Public and private segment players alike need to start making better use of big data and sign agreements with major global laboratories to be able to carry out more of this kind of activity in the kingdom.”

BROADENING ACCESS: According to the 2011 constitution, citizens have a right to accessible, affordable and high-quality health services; however, the World Bank notes that in terms of access to care, Morocco suffers from “glaring inequalities” among its regions and between rich and poor.

Gaps in coverage are particularly concentrated in rural and isolated areas, the WHO’s Souteyrand told OBG, adding, “The authorities have been working on innovative new solutions to improve access to health care in rural areas, notably by launching mobile hospitals. However, this initiative is still young and needs to be properly evaluated before it can be rolled out across the country.”

The organisation is working alongside the government to improve the primary care system, especially in isolated areas, and to develop family medical practices as a first point of contact for patients. These clinics can likely address many problems that would negate the need for patients to turn to hospitals.

INCREASING COVERAGE: In an effort to move towards universal health care, Moroccan authorities are taking steps to extend insurance to those who fall into coverage gaps – many citizens have too high an income to receive help from RAMED, yet do not receive AMO through their employer and cannot afford private health insurance. For the first time, 288,000 full-time students were offered coverage through AMO during the 2015/16 academic year. Authorities are now working to further extend the programme to include independent workers, such as craftsmen, and those in the liberal professions.

To serve that demographic, in 2007 the Ministry of Health introduced INAYA, a measure intended to provide coverage to self-employed individuals. However, the scheme is optional in nature and therefore reached only a very small share of the population: it had around 700,000 members by 2009. It became clear in the early 2010s that the programme was not fulfilling its intended purpose, leading authorities to brainstorm new avenues. Incentivising the use of private cover or expanding AMO are two options.

DRUG COSTS: Traditionally, prescription and over-the-counter drugs have been relatively costly in Morocco, both for medical facilities and individuals paying out of pocket at pharmacies. Health authorities have made concerted and proactive efforts in recent years to bring costs down: El Ouardi reported that the government reduced the price of some 3600 medications during the 2012-16 period.

There has also been a drive to broaden the availability of generic drugs to further lower prices. The country’s first bioequivalence centre at the Cheikh Zaid hospital in Rabat, authorised in 2015, has the goal of increasing access to affordable medications. It completed its first study in October 2016. The efforts to demonstrate bioequivalence of generic drugs will serve to legitimise their efficacy, and should expand their market share. Generics capture 37% of the drug market in Morocco, in line with 39% of total global consumption, according to the June 2017 edition of the publication Infosanté. While use of generics is becoming more commonplace, such medications are still not effectively penetrating the pharmaceuticals business. However, at approximately 30% cheaper than name-brand drugs, generic alternatives are a key tool in increasing the affordability and equality of health coverage.

PRIVATE CARE: For citizens able to afford it, private health care has long been an attractive alternative to the public system. Private facilities may operate on either a for-profit or not-for-profit basis. Not-for-profit hospitals – funded, for example, by the UAE’s Sheikh Khalifa Bin Zayed Al Nahyan Foundation – have a long-standing presence in the country.

A legislative change in 2015 permitted non-medical professionals to establish health facilities in Morocco for the first time, which has dramatically altered the landscape of health services. This reform has greatly expanded the range of potential investors in private facilities, while also making it easier for foreign health service providers to establish a local presence. Before this change, the vast majority of investors and insurance providers were Moroccan. However, since 2015 more foreign players have entered the market. Local stakeholders have reported a considerable spike in interest from international investors, foreshadowing a more competitive landscape in the future. If demand remains constant, increased supply of health services could lead to a fall in prices, which are fairly high compared to average purchasing power.

While the private segment has been relatively dynamic in recent years, its presence is still heavily concentrated in the Northern Atlantic regions, as rural areas have not yet proven to be bankable opportunities for potential investors. Thus far, the government has been supportive of expansions in private health care, as it believes such developments broaden coverage and improve quality.

Public-private partnerships (PPPs) have also become a main feature of Morocco’s health care landscape, starting in the early 2010s. Through PPPs, the public health system can close gaps in coverage by acquiring treatments for its patients from private providers. As of 2017 the government had not yet conducted a value-for-money analysis of its use of such PPP arrangements in the sector, so the practical efficacy of these agreements remains to be seen.

MEDICAL TOURISM: Private players in Morocco’s health sector are beginning to look beyond the local population in search of profits, seeing opportunity linkages with already well-established industries. Arsala from Sheikh Khalifa Bin Zayed Al Nahyan Hospital told OBG, “Given that Royal Air Maroc – the country’s flagship airline – already serves most of the continent, Morocco could become an African health hub. In some respects, this phenomenon is related to the country’s increasing attractiveness as a tourist destination, so patients can combine a holiday with the medical treatment they need. This is a big potential growth area for the future.”

TELEMEDICINE: To meet the needs of patients both abroad and in outlying areas of Morocco where medical infrastructure is still underdeveloped, health care providers are increasingly turning to telemedicine as an alternative to in-person services. Through advances in medical and telecommunications technology, Morocco-based health practitioners can use remote capabilities to extend their reach domestically and capitalise on collaborative business opportunities farther afield.

“This is the next frontier for hospitals like ours,” Arsala told OBG. “We already have partnerships with other African hospitals relating to specific patients and treatments, and we are hoping to expand our network and partner with hospitals across the continent to carry out technical procedures using the latest telemedicine technology.”

GOVERNANCE: While Morocco’s 2011 constitution attempted to move towards greater decentralisation of political and administrative power, delegating authority to the country’s 12 regions, the goal has not yet been met in the health sector. Most key decisions are still made by the Ministry of Health in Rabat, and the subnational institutional framework required for effective decentralisation is yet to be put in place. These governance structures will help facilitate the decentralisation process and should allow local health providers to become more independent, thus increasing their capacity to respond to the unique needs of the populations they serve.

“Budget and staffing issues aside, improving governance of both public and private health care is one of the most pressing issues. Decentralisation of responsibilities to the regional level would be an important step,” Souteyrand told OBG. “At the same time, however, there will be a need to ensure appropriate oversight so quality and standards can be assured across the country. Developments in private health care have, in recent years, outpaced the government’s efforts to govern and regulate it.”

BETTER PLANNING: An important innovation for planning purposes has been the introduction of a systematic roadmapping tool, known locally as the carte sanitaire. This allows government officials to determine which locations in the country are in the most need of which services, thus facilitating a strategic allocation of resources.

This tool could also be extended to private providers; it could encourage the establishment of facilities in the areas of greatest need and prevent the creation of redundant services in areas already saturated by the public or private segment. It may also prove to incentivise providers to locate in regions of the country where projects may not otherwise be bankable. However, as private health providers make up a growing share of the market, additional complications arise: public health authorities must correspondingly increase their regulation and oversight of these providers as their reach expands.

MULTILATERAL ASSISTANCE: In March 2017 the WHO launched its 2017-21 Country Cooperation Strategy with Morocco, built around four core priorities: ensuring universal access to quality health services; reducing mortality, morbidity and inequity; promoting health security; and improving regional impact, especially through decentralisation.

The WHO is working with the government to strengthen primary health systems, with a particular focus on expanding coverage to more isolated areas. Another priority is the development of family practice clinics, which can provide patients with a first point of contact when they have a medical issue. These family practices can direct patients to the most appropriate further treatment in a primary care facility, either at a hospital or at a specialist centre. As these initiatives cannot be instituted throughout the country immediately, they are primarily medium- to long-term in perspective.

OUTLOOK: The epidemiological transition under way in Morocco is expected to continue for the foreseeable future, with non-communicable diseases increasingly being the chief cause of death.

Over the 2017-21 period, a range of financial measures will be needed to support investment in health care to not only meet the country’s commitment through the Abuja Declaration, but also to keep pace with developments in neighbouring countries. Funding efforts are likely to be concentrated on building health facilities in rural regions and addressing the significant staff shortages that leave some clinics and hospitals in disuse.

The government is making significant progress towards universal health coverage by progressively bringing different segments of the population under a multi-pronged insurance model. However, as private health care comes to play a bigger role in the system, there is a growing need for a ministry framework to supervise and regulate the segment.