Morocco passes new legislation to offer more private sector investment in health

Significant advances have been made in improving health care in Morocco in recent years, including the extension of medical coverage and a substantial reduction in infant mortality rates. As the expansion of state-funded medical coverage boosts access to health care for a growing number of people, health facilities are increasingly under pressure to respond to the growing demand for treatment and medicines.

Expenditure

According to the World Health Organisation (WHO), total expenditure on health per capita in Morocco rose marginally to $189 in 2013, up from $181 in 2012. As a percentage of GDP, total health expenditure remained at 6% from 2012 to 2013, whereas in Tunisia and Algeria this figure stood at 7.1% and 6.6%, respectively, in 2013. The government contributed 6% to public health expenditure in 2013, unchanged from 2012. Additionally, out-of-pocket expenditure on health remains comparatively high at 58.4% in 2013, due mainly to the cost of buying medicines. In contrast, this figure stood at 35.3% in Tunisia and 25.1% in Algeria in 2013.

Indicators

Morocco has made significant headway in reducing both maternal and child mortality rates in recent years. Between 1990 and 2010, the country’s maternal mortality rate decreased by 67%, while the under-five mortality rate fell by 60%. In 2013 there were 26 deaths per 1000 live births for children under five years, while the maternal mortality ratio was 120 per 100,000 live births. The government is striving to reduce these rates to 20 and 80, respectively, by 2020.

Indeed, improving these indicators is central to the health strategy for 2012-16, launched by the Ministry of Health (Ministère de la Santé, MS) in 2013 to meet the 2015 UN Millennium Development Goal (MDG) of reducing child and maternal mortality rates by 70% and 82%, respectively, from the levels in 1990. The plan targets 66% of the population in nine regions where it is difficult to access maternal and child health care.

While Morocco appears on track to achieve the MDGs related to improving maternal health and reducing child mortality, the maternal mortality ratio continues to be high, particularly when compared to other countries in the region with similar levels of GDP per capita, such as Egypt (45 per 100,000 live births) and Tunisia (46 per 100,000 live births). One of the main reasons for this lag is the persistent inequality in the provision of health care between urban and rural areas. Maternal mortality in rural areas is 43% higher than in urban areas, according to the African Development Bank.

Insurance

A 2011 constitutional amendment enshrined access to health care as a basic right. Since then, significant efforts continue to be made to expand access to health services, with increasing amounts of public financing in recent years. While considerable advancements have been made through large-scale government projects such as the Medical Assistance Regime (Régime d'Assistance Médicale, RAMED), financed by the MS, over half of the population still had not benefitted from social protection in 2013.

Ramed

RAMED was introduced in 2009 with the aim of providing 8.5m impoverished people with medical insurance to enhance access to the country’s public health network, including services and medicines. The goal set by the government has nearly been reached, with 8.1m beneficiaries by February 2015, representing 96% of the target population. While the programme covers 28% of the population, another 33% is insured under the employer-based basic state health insurance scheme, or Assurance Maladie Obligatoire (AMO), initiated in 2005. In 2013, AMO covered 8m people, up from 7.6m in 2012. However, the remaining 39% of the population does not have basic medical coverage.

The next step, which authorities are currently working on, is to extend coverage to the uninsured population, including “independent workers”. Though the task is expected to be challenging due to the substantial size of the informal sector – estimated by Carnegie Middle East to be around 30% of the workforce – this phase will be an important addition to increase coverage in the broader universal health care plan.

In July 2015 the government approved a draft law to extend the compulsory insurance scheme to local and foreign students enrolled in public and private institutions of higher education in Morocco. Students of private institutions will, however, be required to pay a membership fee. The insurance cover will come into effect in September 2015. The number of university students in Morocco was estimated at 657,000 in 2014.

“The remaining challenge is to ensure that the services available are able to meet rising demand. There is currently a lag between the growing demand for health services, resulting from the increasing population with free medical coverage, and the availability of services, which is evolving at a slower rate,” Yves Souteyrand, the WHO representative in Morocco, told OBG.

Infectious Diseases

Morocco has been successful in eradicating malaria since 2007 and was not affected by the spread of the Ebola virus in 2014, despite being a main transit hub into and within Africa. Treatment and prevention efforts have largely kept the spread of HIV at bay; the national prevalence rate is a stable 0.1% among the general population. The country continues to combat incidence of tuberculosis.

The continuous improvement in living standards over the years has resulted in an epidemiological shift with a steep reduction in the prevalence of communicable diseases and a steady rise in chronic illnesses. Strong immunisation policies have contributed significantly to reducing the spread of infectious diseases in Morocco, though some problems persist, notably tuberculosis. According to WHO, the prevalence of tuberculosis stands at 104 per 100,000 people; however, it remains lower than the regional average of 180. In 2013 the MS established a national anti-tuberculosis strategy to eliminate the disease, aiming to reduce its prevalence by 6% each year. Morocco has a detection rate of 85% and treatment is free, according to the World Bank.

Chronic Diseases

As a result of the epidemiological shift away from infectious diseases, life expectancy at birth is increasing in Morocco, up from 58 years in 1980 to 71 years in 2013 – 73 years for women and 69 years for men. The ageing population faces an increasing number of cases of chronic illnesses. Around 75% of deaths in Morocco today are related to chronic diseases, resulting from increased longevity as well as changes in lifestyle and behaviour patterns. According to WHO figures, cancer accounts for 11% of deaths in Morocco, diabetes for 12% and cardiovascular diseases for 34%. However, Morocco is not alone in the region to experience rising rates of chronic illnesses, a challenge faced by many countries with similar levels of GDP per capita. While 75% of deaths in Morocco are caused by chronic illnesses, this figure stands at 82% in Tunisia and 85% in Egypt.

Overall, chronic diseases are on the rise, increasing from 13.8% in 2004 to 18.2% in 2011, with some 30, 000-54,000 new cases of cancer diagnosed in Morocco each year. However, significant efforts to prevent and treat the disease are being made, notably through a national strategy as well as diagnosis and treatment centres backed by the Lalla Salma Foundation. Established in 2005, the foundation has taken part in devising a strategy to fight the disease and setting up diagnosis and treatment centres nationwide.

In October 2013, the foundation inaugurated a breast and uterine cancer screening and early detection centre in Mohammedia. The Dh4m (€355,000) project was carried out by the foundation, the MS, the National Initiative for Human Development, the region of Greater Casablanca and the commune of Mohammedia. The centre is expected to offer services to the populations of Mohammedia, Bouznika and Benslimane. Moreover, a new Institute for Cancer Research has also been under construction since November 2013 at the Hassan II University Hospital Centre in Fez. The Dh14m (€1.2m) project was launched by the foundation in collaboration with the Ministry of Higher Education and Research and the MS.

Geriatrics & Mental Health

With slowing population growth, lower fertility rates and longer life expectancy at birth, Morocco is looking to address the current and potential needs of its ageing population. The number of people aged 60 and older increased from 1.8m in 1994 to 2.3m in 2004, and the group was expected to reach 3.2m in 2014 and 4.1m in 2020.

In January 2015 the minister of health, Houcine Al Ouardi, revealed in a parliamentary session that some 48.9% of Moroccans currently or have in the past suffered from a psychological disorder. The minister also acknowledged the lack of infrastructure in hospitals to treat psychological illnesses.

Care for mental health patients is increasingly gaining importance in Morocco with the development of a national strategy to improve the quality of mental health services. In July 2015 a draft law was adopted to protect the rights of people with mental disorders, in a full review of the 1953 law on mental health. Health professionals were reportedly surprised by the contents of the bill, telling local media that the bill had been pushed through parliament quickly and without consultation from the Moroccan Society of Psychiatry or the Association of Private Psychiatrists. Following criticism from health professionals, Al Ouardi agreed to meet with representatives of the groups to review the content of the draft law and allow them time to submit proposals for the bill’s amendment.

Plans are in place to deal with the shortage of mental health infrastructure through the construction of three regional psychiatric hospitals in Agadir, Kenitra and Kelaa Sraghna. These hospitals will add to the 27 public facilities that currently specialise in the treatment of mental illnesses in an effort to reach a government goal of 3400 beds by 2016, up from some 2453 beds at present. In addition to these hospitals, plans are in place to develop four more facilities specialising in child psychiatry in Casablanca, Rabat, Fez and Marrakech. While Morocco looks to improve facilities, the shortage of qualified personnel represents another challenge to the sector. According to figures from the MS, there are currently 320 psychiatrists practising in Morocco, one for every 100,000 people in the country. Efforts are under way to increase training for mental health professionals, with the goal of training some 30 psychiatrists and 185 specialised nurses each year PRIVATE SECTOR:The private sector has seen considerable development over the past decade. There are 332 private clinics with a combined total of 8400 beds, representing 23% of total bed capacity in Morocco. The number of private doctors’ offices nearly tripled in the past two decades, rising from 2552 in 1991 to 7310 in 2011. However, the distribution of private services remains unequal, with services primarily concentrated in the country’s urban areas.

A legal reform passed in February 2015 has drastically expanded investment opportunities in the private health care sector. Before 2015 only certified doctors could invest in private clinics, but the newly adopted law on medical practice enables local and international private investors who are not medical professionals to open private health facilities in Morocco, thereby unlocking a sector that has been on the investment radar for some time. Despite concerns over commodifying the health sector and a drain of staff from public facilities to private operations, the new law aims to expand and improve the distribution of health services across the country. The goal is to strengthen medical services and extend the network of private clinics to help increase access to health services in rural areas. In addition, private facilities are also required to post their prices and undergo regular audits.

According to Souteyrand, the inclusion of non-medical investors will enable specialists from other fields to bring their expertise to the sector. “The idea is really to increase the availability of health services and ensure that facilities in the private sector are better managed. Allowing investors from outside the health professions to invest in health care in Morocco could increase the management abilities in these facilities, but the challenge is to ensure that the additional supply of health services in the private sector will match the needs of the population, notably geographically,” Souteyrand told OBG. In addition, with the expected rise in foreign private investment, the country’s network of private clinics might prove attractive to medical tourists from Europe and other countries in Africa.

Expanding Infrastructure

The public sector remains the primary provider of health care in Morocco, with more than 65% of total bed capacity, 57.5% of doctors and 64% of specialists. Public infrastructure includes 147 hospitals and 2759 basic health care facilities. Numerous new projects have been developed in Morocco in recent years, including university hospitals in Fez, Marrakech and Oujda. Such improvements in infrastructure have also enabled university hospitals to provide advanced and high-quality care. In contrast, the quality of infrastructure offered in primary health care facilities and the investments made in improving infrastructure at this level remain limited.

The expansion of medical coverage has considerably increased demand for health services, particularly in terms of primary health care facilities, and as a result services and facilities are struggling to keep pace.

Staffing

Furthermore, the country continues to face an endemic shortage of doctors and nurses, particularly in rural areas. The human resources deficit is one of the most significant challenges in the health sector today. Morocco has a relatively low density of medical personnel that is unevenly distributed, with health care professionals primarily concentrated between Tangiers and Casablanca, making the situation in rural areas particularly difficult. There are 6.2 doctors per 10,000 people in Morocco, a relatively low count in comparison to other countries in the region such as Tunisia with 11.9 and Algeria 12.1. The MS aims to increase the national ratio to 10 doctors per 10,000 people by 2020 by adding 3000 new doctors each year.

Despite these efforts, there continues to be an estimated shortage of over 6000 doctors and 9000 nurses. Foreign nationals are currently not permitted to practise in the medical field in Morocco. In contrast, “the volume of Moroccans leaving the country to practise in the medical profession abroad is substantial and contributes to the deficit in staffing at the national level,” Souteyrand said. In an effort to mitigate the problem, faculties of medicine in Moroccan universities are expanding to increase training capacity and provide a higher number of qualified professionals.

With family medicine largely unpractised in Morocco, preventive care has been limited. According to a study by the Institute for Women’s Policy Research, just 5% of the population reported visiting a health care provider or family doctor for annual check-ups. However, the introduction of family medicine is a priority in the MS national strategy for 2012-16. A new curriculum will be used for the first cohort of family doctors at the National School of Public Health in 2015.

Medicines

While access to medicine has improved in recent years with an increasing number of patients seeking free medical care through RAMED and AMO, the high cost of medicine continues to be a challenge, with medications constituting 29% of AMO’s expenses. In an effort to increase access, price reductions of medicine were introduced by the government in 2013. The policy initially mandated price reductions on 800 medicines, eventually extending this to a total of 1311 products. However, the penetration of quality generic drugs, which cost on average 30% less than original medicines, continues to be low at only 30% of the national market. Competition among generic producers in the country is also on the rise. “There are too many actors in the generic pharmaceutical industry. Since they have lower margins, generic producers are especially impacted by price decreases,” Abdelghani Al Guermai, CEO of Laboratoires Pharmaceutiques Galenica, told OBG.

To add to this competition, the Moroccan Office of Industrial and Commercial Property signed an agreement in 2015 with the European Patent Office rendering patents registered in Europe valid in Morocco, thus putting further pressure on access to generics in Morocco. While the agreement will protect European patents in Morocco, medicine exports from the country, which account for some 10% of national production, are currently destined exclusively for other African countries.

Pharmaceuticals

The pharmaceuticals sector has seen considerable growth over the years, and in response to growing demand for medicines, the number of manufacturing units has increased from 32 in 2011 to 40 in 2014. The industry is concentrated and largely dominated by the subsidiaries of multinational pharmaceutical companies, with the largest four manufacturers holding 44% of the market, and 95% of the market held by the top 20 performers. Industry activities generate a turnover of about Dh10bn (€1.1bn) per year, with annual per capita spending on medicines in pharmacies accounting for Dh408 (€44.4).

The industry is open to foreign investment with reduced tax rates for export companies, though the government has not provided specific incentives for the sector. Nearly 8% of national production is exported, primarily to Europe and other African countries. Though national production covers 65% of local demand, the national market for pharmaceuticals remains constricted due to weak purchasing power.

Outlook

The provision of health services by the private sector is expected to increase in the future, but the pressing issue of human resources will determine the extent to which the government can expand and improve health services to reduce the persistent disparity between urban and rural areas. Though advances in medical coverage through the expanded medical insurance scheme have increased access to health services, further improvements to infrastructure will be needed to ensure the ability of health facilities to respond to the higher demand driven by the expanding population and improving economic conditions.

As life expectancy continues to rise in Morocco, the growing number of people affected by chronic diseases as well as an increasing demand for geriatric and mental illness services will continue to present opportunities in the sector. Recent legal changes to requirements for investment in the private health care sector will also contribute to an increase in business opportunities and the availability of health care facilities.