Morocco ramps up health care spending to build on recent progress

Moroccan health indicators have improved steadily in recent years, although there remains room for improvement, even by regional standards, and as in many countries, the burden of lifestyle-related non-communicable diseases (NCDs) is on the rise.

Access to health care coverage has also been growing rapidly as the authorities roll out government-backed insurance schemes to an ever-growing number of citizens, with the country aiming to achieve near-universal coverage in the coming years. Meanwhile, recent regulatory changes have opened up the private sector to increased investment, and the public sector has been gaining ground on the former in terms of its level of spending.

Structure & Oversight

The Moroccan health sector is overseen by the Ministry of Health (MoH), which manages the kingdom’s state hospitals and other public health care infrastructure. It is also responsible for implementing health policy.

In terms of health care expenditure, the private sector accounts for 55.7% of total spending, compared with 43.3% from the public sector, according to 2015 figures from the World Bank. The public sector’s share of expenditure has risen significantly since 2000, when it stood at 25%, due to the implementation of government-backed health insurance schemes. Nonetheless, it remains low by regional standards, accounting for 57% of total spending in Tunisia and 68% in Algeria. Regarding the workforce, data from state planning and statistics body the High Planning Commission (Haut-Commissariat au Plan, HCP) shows 23,361 doctors were employed in 2017. This was split nearly 50:50 between the public and private sectors, with 11,167 and 12,194 doctors working in each, respectively.

In addition to private health care providers, several non-governmental organisations also play a significant role in the sector, including the Lalla Salma Foundation for the Prevention and Treatment of Cancer, which has overseen efforts to raise awareness of the disease and improve cancer care.

Sector Spending

The MoH’s budget under the 2018 Finance Law was Dh14.79bn (€1.3bn) and rose by 10.4% in nominal terms to Dh16.33bn (€1.5bn) in the 2019 budget. The increase was in keeping with the government’s stated intention to deliver a “social” budget that addressed socio-economic issues such as health care and education. The decision to focus on these areas followed a speech given by King Mohammed VI in summer 2018 on the 19th anniversary of his ascension to the throne, in which he called for greater progress on social challenges.

The 2019 budget figure comprises current spending of Dh13.01bn (€1.2bn) and investment spending of Dh3.25bn (€292.3m), with the latter representing a 44.4% increase on the previous year. The MoH budget is equivalent to 4.5% of total government expenditure and 1.3% of national GDP, based on the IMF’s forecasts for the indicator published in its latest World Economic Outlook from October 2018.

Looking at wider sector spending, total current health expenditure was worth 6% of GDP in 2016 at Dh61bn (€5.5bn), according to the latest figures from the World Health Organisation (WHO). As a percentage of GDP this is slightly less than Tunisia and Algeria, which both registered spending equal to 7% of GDP. In per capita terms, Moroccan expenditure was $171 in 2016, up from $54 in 2000.

Out-of-pocket expenditure accounted for 49% of total current health expenditure in Morocco, down from a peak of 59% in 2005, pointing to rising levels of coverage by state-backed insurance schemes. Nevertheless, the figure is high by regional standards, standing at 40% in Tunisia and 31% in Algeria.

Heath Policy

The development of the sector is guided by four-year strategic government plans, with the latest being the Health Sector Strategy 2017-21. The plan’s objectives include improving the capital resources of hospitals; expanding medical coverage to include individuals who are either self-employed or in liberal arts professions; decreasing the incidence of cardiovascular diseases and hepatitis C; increasing the number of employees in the health sector; standardising the type of education that Moroccan medical students receive; and lowering the price of pharmaceuticals.

In April 2018 the Council of Ministers approved the broad targets for the next version of the strategy, known as Santé (Health) 2025. The plan is based around three pillars: organisational initiatives to expand available care and improve access through measures such as the expansion of the public hospital network and the development of mobile health care services in rural areas; the strengthening of national health programmes and campaigns against specific diseases, including a focus on consolidating existing mother-baby-oriented care programmes; and improvements in governance and the allocation of resources in the sector, including efforts to address what the government describes as a shortfall in human resources in the sector.

According to state estimates, Santé 2025 will require an investment of at least Dh24bn (€2.2bn) to achieve these targets, including Dh10bn (€899.4m) to bolster health programmes and campaigns against particular diseases already in place, and Dh14bn (€1.3bn) to upgrade the kingdom’s hospital infrastructure. Of the total, Dh2bn (€179.9m) will come directly from government funds already in place, Dh8bn (€719.5m) will be raised through borrowing and public-private partnerships, Dh1bn (€89.9m) through new taxes, Dh2bn (€179.9m) from international donors, and Dh1bn (€89.9m) from other domestic sources. Other health-related reforms being worked on by the authorities in addition to Santé 2025 include a new emergency care strategy, as well as a pharmaceuticals strategy.

Major Health Indicators

The kingdom’s key health indicators have been improved steadily since the turn of the century. For example, average life expectancy at birth stood at 75.8 in 2016, according to the latest World Bank estimates, up from 68.7 in 2000. Women are expected to live until 77 years of age, while for men the figure is lower at 74.6.

Life expectancy in Morocco is slightly higher than in Tunisia, where the average is 75.7, but less than in Algeria, where it is 76.1. In terms of the wider region, the Moroccan figure is substantially higher than the MENA average of 73.5, despite Morocco being one of the lower-income countries in the region. Local life expectancy is even higher than the average of 73 years of age recorded in the MENA region when high-income countries were excluded from the sample. This is partly explained by the regional average being brought down by the effects of conflict in countries such as Iraq and Syria, rather than exceptional outcomes in Morocco.

The infant mortality rate has seen vast improvements, too, from 144.2 per 1000 live births in 1960 (shortly after independence) to 42 in 2000 and 20 in 2017. While this rate is in line with Algeria and the MENA region, it is nearly twice of neighbouring Tunisia. The prevalence of childhood stunting has also fallen rapidly, from 23.1% in 2003 to 14.9% in 2011. Maternal mortality stood at 121 per 100,000 live births in 2011, down from 221 in 2000. While the figure was similar in Algeria, Tunisia recorded significantly fewer deaths, at 62 per 100,000 births.

Public Health Facilities

There were 155 public hospitals in the kingdom in 2015, according to the HCP. As of 2013 – the latest year for which HCP data is broken down by hospital type – there were 105 general and 38 specialised hospitals in the kingdom. Public hospitals had a combined bed capacity of 22,075, with an occupancy rate of 63.8%.

The hospital network is set to expand in line with government plans to improve access to care under the current strategic plan for the sector. To this end, construction work on eight new hospitals with a combined capacity of 1050 beds was launched across 2017 and 2018, with plans for 14 new facilities under the Health Sector Strategy 2017-21.

The best-performing hospitals in Morocco, according to the Ranking Web of World Hospitals – which is an initiative from Cybermetrics Lab, a research group of the Spanish National Research Council – are the publicly funded Centre Hospitalier Mohammed VI in Marrakech, which is 3133rd in the ranking, followed by the Centre Hospitalier Universitaire Ibn Rochd Casablanca, another public establishment, which is placed 5189th.

Some stakeholders have highlighted that the country’s best care facilities are disproportionately concentrated in major population centres such as the Rabat-Casablanca area, resulting in significant regional inequality regarding access to high quality facilities. One project seeking to address this is construction of a 500-bed university hospital in the Laâyoune-Sakia El Hamra region in the south, which is the second smallest of the 12 regions by population. The development is scheduled for completion by 2022 at a cost of Dh1.2bn (€108m).

Private Sector

Private health care providers have also been expanding medical infrastructure. For example, in June 2017 the Evya Clinic Network opened the 171-bed Hôpital Privé de Marrakech, and Elsan, a private France-based health operator, constructed a 136-bed facility in the Bouskoura municipality of Casablanca called Clinique Ville Verte, which was inaugurated in January 2018.

There are around 360 private health care clinics operating in Morocco, according to US Department of Commerce figures, and over 12,000 doctors working in the segment. Until 2015, only doctors were permitted to own private clinics, but legislation passed that year removed this restriction, allowing both Moroccan and foreign individuals to establish clinics regardless of their profession.

Access to Care

Article 31 of the constitution stipulates that Moroccans have the right to health care. The stipulation was one of several major reforms made to the constitution in 2011. Speaking to media in early 2018, Anas Doukkali, the minister of health, said that 64% of Moroccans currently benefit from health coverage, a figure the authorities intend to increase to 90% by 2021.

Insurance Schemes

There are two main public health insurance schemes. One is an employer-based plan known as Compulsory Health Insurance, which was launched in 2005 and provides coverage to workers in both the government and private sectors, as well as their dependants. Through the plan, patients are eligible to have 70% of the cost of their private health care treatment and 80% of the cost of their public treatment reimbursed. The scheme was extended to higher education students in 2016, although uptake by students has been weak to date, leading the government to issue a new decree in August 2018 to try to address some of the procedural issues underpinning the problem. In total, 9m Moroccans received health coverage from the scheme as of the end of 2017, according to the Supervisory Authority of Insurance and Social Security (Autorité de Contrôle des Assurances et de la Prévoyance Sociale, ACAPS).

The second main scheme is the Medical Assistance Regime (Régime d’Assistance Médicale, RAMED), which was launched in 2009 to provide cover for low-income Moroccans, such as those working in the informal sector. As of September 2018, around 12m citizens were covered by RAMED. Members of the Moroccan armed forces are covered by a third government-backed scheme.

In a positive sign for the sector, the uptake of smaller health insurance segments has risen, with total premium for sickness and maternity cover valued at Dh3.26bn (€293.2m) in 2017, up 7.8% on the previous year, according to ACAPS.

Epidemiological Transition

Morocco, like many countries, has recently undergone a process of epidemiological transition away from a high burden of communicable diseases. This has largely been the result of successful efforts to reduce poverty.

However, the incidence of some communicable diseases remains significant, particularly among poorer segments of the population. For example, there were still 99 cases of tuberculosis per 100,000 people in 2017. This did represent an improvement from roughly 115 cases per 100,000 at the turn of the century, according to WHO estimates, although progress has been unsteady.

Meanwhile, the death rate from the disease fell from 9.3 per 100,000 people to 8.1 over the same period, again subject to occasional reversals in improvements. In July 2018 the government said it intended to eliminate the disease from Morocco by 2030. Hepatitis C remains another substantial communicable public health threat.

Nonetheless, NCDs now represent the biggest threat to health in Morocco. Together, such diseases are thought to account for around four-fifths of all deaths. The growing burden of NCDs has been driven substantially by lifestyle trends, with both tobacco smoking and obesity on the rise.

Diabetes is an example of the growing threat from NCDs and prevalence of the condition stood at 7.14% of the population in 2017. This was slightly above the rate in Algeria (6.7%), but below that of Tunisia (8.5%), the wider MENA region (11.4%) and the MENA average excluding high-income countries (10.6%). However the local situation has worsened over time: 13.7% of Moroccans had raised fasting blood glucose levels in 2014 according to WHO estimates, up from 9.1% at the start of the decade.

The goals of Santé 2025 suggest the state is prepared to further mobilise efforts to address the rise in NCDs, and to date Morocco has made strong progress in improving cancer awareness and treatment, in particular. The latter has been the result of a 10-year cancer plan launched by the Lalla Salma Foundation that runs to the end of 2019. In total, 17 centres for disease detection and treatment operate under the organisation’s umbrella.

Doukkali said in September 2018 that one of the government’s priorities for health care was treating cancer in children, of which there around 1200 cases a year, and that previous efforts in this domain had brought the survival rate up from 10% to 50%.

The authorities are also taking public health measures to reduce the incidence of NCDs, including a tax on sugary drinks introduced in the 2019 budget. A national programme to educate people about the importance of healthy lifestyles is also being prepared and is backed by a major study that has been completed on the prevalence and incidence of diabetes and cardiovascular diseases.

Pharmaceuticals

The value of local pharmaceutical sales was nearly $1.5bn in 2017, according to the “Morocco Pharmaceuticals and Healthcare Report” by Fitch Solutions. Around 40% of this local consumption, by value, comprises generics, as per mid-2018 figures from the Moroccan Association for the Pharmaceuticals Industry (Association Marocaine de l’Industrie Pharmaceutique, AMIP). The proportion rises to 70% when only including the public health sector, and the overall figure represents a more than 10-percentage-point increase on the contribution of generics to sales since 2010.

In total, 28 pharmaceutical manufacturers operate in Morocco. Two-thirds of these are domestic firms, while the remainder are subsidiaries of foreign companies. With a combined turnover of around Dh15bn (€1.4bn) per year, local businesses produce both generics and original drugs under licence from foreign firms. In all cases, companies import the primary ingredients for medicines, as there is not the capacity to produce them locally.

“The level of local drug production is constantly falling. Today, only 60% of domestic demand is met by Moroccan manufacturers, which results in the degradation of Morocco’s commercial balance and foreign currency reserves,” Ali Sedrati, president of AMIP, told OBG. “Another worrying trend is the slowdown in industrial investment due to a lack of incentives provided by the current legal framework.”

Local research and development (R&D) activity also remains relatively small-scale, with the sector’s R&D budget worth Dh76m (€6.8m) as of 2016. A law allowing for clinical trials in the kingdom is in place, but industry figures say that the sector is still waiting for regulatory decrees to be issued.

“The legal framework for clinical research exists, but we are still waiting for the application decrees to be published,” Taher Hassen, general manager of Morocco and Tunisia at Merck, a US-based pharmaceutical company, told OBG. “This will further regulate and improve the R&D framework in Morocco.”

Medical Technology

The US government estimates the size of the Moroccan medical device market at around $236m. Indeed, the domestic medical devices segment is less developed than the domestic pharmaceuticals industry, with around 90% of local consumption supplied by imports.

“The main challenge for the Moroccan medical technology sector is its inability to produce machines at a globally competitive price point,” Naoufal Lahlou, general manager of PROMAMEC, a domestic surgical products wholesaler, told OBG. “Unfortunately, the other international actors in the industry benefit from substantial government subsidies and incentives, and this undercuts the potential competitiveness of local manufacturers.”

Outlook

While numerous health indicators, including life expectancy and infant mortality, have seen substantial improvement in recent times, lifestyle changes concomitant with economic development could make tackling the rising burden of NCDs a challenge. Nonetheless, an increase in the sector’s budget allocation for 2019 suggests that public health is being prioritised in government planning. Continued investment will be necessary over the longer term, however, particularly if the goal of universal health care coverage is to be achieved.