Morocco: Morocco Health Profile

Healthy growth

Health care in Morocco is expanding rapidly at both ends of the socioeconomic spectrum, thanks in among to the rollout of a new government scheme to extend free coverage to low- benefits citizens, along with an increase in private investment in elective care facilities to attract medical tourists.

Moroccan per capita health spending has been rising significantly in recent years, growing from $99 in 2004 to $156 in 2009, according to World Bank data. As a percentage of GDP, spending on health rose from 5.2% to 5.5% over the same period. Private spending on health, which stands at around 4% of GDP, currently accounts for the bulk of this, with public spending accounting for just 34% of total health outlay.

Nevertheless, public spending seems set to increase significantly in both proportional and absolute terms, given plans to roll out the Medical Assistance Scheme for the Economically Deprived (Régime d’Assistance Médicale des Economiquement Démunis, RAMED) across the country in December. A pilot version of the scheme was launched in 2008 in the central region of Tadla-Azilal and benefitted 40,000, with widespread acceptance among amount health professionals. Under RAMED, 8.5m Moroccans living below the poverty line, or just under 30% of the people, will benefit from partial or total exemption from the costs of treatment at public hospitals.

In mid-August Prime Minister Abbas El Fassi presided over the creation of three technical committees that will prepare the ground for RAMED’s national roll-out. In the build-up to its expansion, the Ministry of Health has been ramping up its pharmaceuticals procurement budget, which increased from Dh50m (€4.3m) in 2008 to Dh1.4bn (€121m) in 2010.

As national-provided health care provision for low- benefits Moroccans expands, at the other end of the market the country is starting to emerge as an significant health tourism destination for European patients. While a lot of other countries, including nearby Tunisia, now offer low-cost quality health care, Morocco boasts several key advantages over its competitors.

These include its proximity to Western Europe, along with the prevalence of French. The fact that the country boasts an extensive tourism infrastructure is as well a key factor in its attractiveness, as is the climate, which is a significant draw for those wishing to combine minor procedures with holiday-style recuperation.

Given that European national-backed health insurance schemes will generally not cover the costs of treatment abroad, the largest increase segments are procedures such as cosmetic and laser eye surgery and dental implants that are deemed non-essential and would accordingly not be reimbursed to a significant degree anyway. Cosmetic surgery in Morocco, for example, can cost between 30% and 50% less than in Europe.

The country hosts around 80 specialists in the field and 10 specialised clinics. Around 15% of the approximately 14,500 instances of cosmetic surgery that take place annually in Morocco involve foreign patients. Women account for around 75% of foreign patients, with liposuction and breast enhancements reported to be the majority frequently performed operations.

The dental tourism segment is as well fast emerging and is attracting older patients from Francophone European countries such as France, Belgium and Switzerland, in particular, inclunding Moroccan immigrants living in Europe. Dental implants, for example, are approximately 50% cheaper in Morocco than in Western Europe.

As it expands, the health tourism segment is attracting foreign investment, as demonstrated by Portuguese group Malo Clinic’s plans to open a Dh280m (€24.1m) clinic and surgery by the end of the year in Dar Bouazza, 20 km south of Casablanca, in cooperation with local dental surgeon Saad Zemmouri. The facility, which will employ 40 specialists and will include a five-star hotel and a health spa, is principally targeting older and retired Europeans. It will specialise in areas such as laser eye, dental and plastic surgery.

Health Care System

In 1956, when Morocco became independent, there were only about 300 public health physicians and 400 private practitioners in the country. Since then, the government has made health care services extra widely available and improved their quality. By 1992, health care was available to 70% of the people. Health education courses at schools and colleges, and programs to teach hygiene to children and parents, have as well helped raise the quality of health. The current life expectancy is 66.5 years for men and 70.6 years for women.
Most health providers and health care centers are located in urban areas. In rural areas, mobile medical teams and a group of pharmacies and clinics provide outpatient care. Efforts to improve health care in Morocco have been hampered by problems with waste disposal, the limited availability of safe drinking water and the rapid increase of the people. The government has been working to improve sanitation and the quality of drinking water.

In 1982, the Ministry of Public Health was formed. Since then, smallpox has been eliminated, typhus outbreaks are less frequent, and malaria and tuberculosis have been brought under control. The World Health Organization and UNICEF as well support the government’s campaigns to reduce eye disorders and sexually transmitted diseases.

Employers in industry and business are required to register their workers for benefits, but a lot of workers are still not covered. A lot of other programs aiming at extending medical care to needy Moroccans are under way. During the early eighties, there was a decline in the in general national supremacy. With the world economic crisis, the National had to face a profound financial crisis leading to the adoption of restrictions and improves. The coming of Alma-Ata declaration offered the opportunity to focus on the prevention of disease and the development of basic health care and health programs. Since then, prevention became the national priority while hospitals were left in the shadow of health policies. The Medical Doctors showed a growing interest in the liberal medicine. The development of the private sector increased in the urban area and in the majority promising regions of the country, independently from the National.

Organizational structure of public system

Since the formulation of the first health policy in 1959, the Moroccan health system is organized with a predominance of the public sector, characterized by the free health care services and the centralized management. The National is positioned at the midpoint of the health system performing at once the functions of financial source, administrator and health care provider. The Ministry of Health runs the Basic Care Health Network, Hospital network and the National Institutes and Laboratories. The Defense department runs its own hospitals and services and local governments have Municipality health services. Over the years, the private sector developed progressively, functioning independently in most cases. The Basic Health Care network comprises of 2458 Health Facilities responsible for curative and preventive ambulatory care + Collective health prevention. The Hospital network comprises of 124 hospitals with 25,000 beds, including single specialty hospitals, semi-autonomous hospital centers, University and hospital centers. The National Institutes and Laboratories are primarily responsible for preventive activities and research and extend their expertise in hospital and ambulatory care and
training.

Key organizational changes over last 5 years in the public system, and consequences

Public sector has undertaken a modernization of its infrastructure and management processes regarding human resources and data technologies in use.Responsibility and anticipatory management are gradually replacing a rigid and less reactive bureaucracy. Nevertheless, salaries in government services reduce considerably the resources allocated to development strategy to alleviate this salary mass is currently being contemplated.

Planned organizational improves in the public system

Since 90’s Morocco has initiated a process of improves in some vital sectors of the public government and its political, economic and social environment. Improves of public government, public spending, labor code, family code and other legal improves make way for the public sectors to modernize themselves and try to adjust their actions to satisfy the people requirements and to meet national and international politicoeconomic changes.

Modern, for-profit

Morocco has over 269 private units, which make up a total capacity of about 5,500 beds.  Half of this capacity is located in Casablanca and the rest is distributed between Rabatand the other largest cities of the country. Some infrastructures are of medium size and possess some of the majority sophisticated equipment with a capacity of 50 to 100 beds, whilst the vast majority is small clinics with a capacity of less than 30 beds and limited resources. Despite largest development during the 90’s, the sector is now in crisis due to competition amongst hospitals belonging to the Department of Social Security, overconcentration in large cities, the limited purchasing power of the large majority of the people and the lack of financing. Government control is exercised at equipment level. In clinics that have been practicing for at least 10 years, specifications have been imposed which define the minimum technical level required.

Modern, not-for-profit

This sector is represented by health care establishments run by mutual benefit societies, the National Social Security Fund (CNSS) and the National fund for social security organisms (CNOPS). These institutions provide health care to employees of private and  public sector respectively. Currently 13 CNSS polyclinics are functional with 1138 beds (98). The sector employs 305 physicians, 1720 male nurses, and 6 pharmacists on permanent basis, while 127 physicians work among time.

Traditional

Traditional medicine sector remain active, particularly in the disadvantaged suburbs and among the populations with low socioeconomic level. There is lack of reliable data about expenses assigned to the care prescribed by the healers and traditional midwives. The impact on users’ health status is as well unknown.

Key changes in private sector organization

During 80’s and 90’s, private medical sector underwent an significant development. Centers of specialized cares, with advanced healthcare technologies appeared in the large urban centers, especially in the cities with university hospital centers.

Public/Private interactions (Institutional)

In the recent years, a lot of projects of partnership have been developed between the Ministry of Health and the NGOs operating in the sector of the reproductive health or the enhancement of rural women’s status. Other memorandums of agreement focus on youth health or the protection of the environment. MoH leads a survey to assess the potentialities and the profits of a public—private partnership in health activities.

Public/private interactions (Individual)

In Morocco, the legislation controls the employ of physicians of the public sector in the private sector. University physicians are allowed to work two half days per week in private health institutions. This policy is often contravened and the liberal physicians often show their dissatisfaction about facing an unfair competition. Other mode of partnership between the two sectors is agreements passed between the Ministry of Health and the liberal physicians, in order to reduce medical training insufficiency in public hospitals. Leasing is another example of public-private interaction. This rental procedure allows public healthcare institutions to make available services involving costly health care equipments such as haemodialysis generators.

The health system is organized according to a pyramidal hierarchy. Structures of primary healthcare (clinics, urban and rural health centers and local hospitals in rural districts for the public sector; medical offices and infirmaries for the private sector) represent the first resort for the patients. They provide preventive and promotional cares inclunding ambulatory curative cares.

The second recourse corresponds to the provincial and prefectorial hospitals for the public sector and the specialized offices and clinics for private one. The third recourse includes regional hospital centers. Fourth recourse is the university hospital centers, one each in Rabat, Casablanca, Fez and Marrakech, where secondary healthcare requiring high-tech equipment and logistics is being provided.

The semi-public sector comprises of health care institutions managed by health insurance organization (CNOPS and CNSS) and other semi-public institutions (office chérifien of the phosphates; national office of the railways etc). They provide curative ambulatory and hospital cares.