The Road to Universal Coverage by the End of 2022, the Moroccan Challenge

Abstract

In the midst of a pandemic, Morocco is generalizing its social protection by 2025 and above all its health coverage by the end of this year, by enrolling 22 million beneficiaries in health insurance. How will a health system, already marked by numerous failures, be able to absorb 22 million new beneficiaries in order to reach 100% medical coverage of the Moroccan population by the end of this year? This is a commendable project, but it risks being a missed opportunity if we do not change the paradigm, governance, and organization of the Moroccan health system upstream in order to make it more efficient and more equitable. What are the obstacles and difficulties encountered by the health system, and what are the accompanying measures undertaken to accompany the overhaul of the Moroccan health system?

1. Introduction

Morocco is a country where public and private health care coexist. Similarly, in terms of financing, it is a multiple system that includes a basic compulsory health insurance scheme and mutual insurance companies and private insurance companies that provide basic and/or supplementary medical cover.

The Moroccan health system is confronted with a multitude of problems linked essentially to the double demographic and health transition, to the insufficiency of the sector’s resources, and to the inequity in the financing of care.

In order to overcome these dysfunctions and improve the health of the population and ensure equality of access to care, the public authorities have embarked on a huge reform project concerning medical coverage and health financing.

The financing of the health system in the different countries of the world can be classified into two groups:

In most high-income countries, the health financing system provides universal health care coverage, whether through taxes or through social health insurance, thus avoiding households having to pay for care out of their own pockets when they need it, called a prepayment system.

In poor countries, with limited government resources, households often contribute directly to health financing by paying for care when and where it is received, known as a user-paid provider fee system, with the great risk of committing the population to catastrophic expenses.

The consequences of these can be devastating, as they can lead to massive debt, loss of assets, sale of essential assets, and even a spiral of poverty. To mitigate this risk, many countries are establishing social security, universal health insurance, or financial aid systems to help low-income people access health care without incurring catastrophic expenses. The development of equitable financing systems is therefore essential to improve access to health care and protect the poor from the catastrophic costs caused by poor health. It is therefore necessary to find effective social protection strategies, favoring risk pooling and prepayment systems, and not direct payment by the patient of health care providers which discourages the poor from using their services [1].

The level of overall health expenditure in Morocco is low and unit prices are high. Since 1997-1998, several efforts have been made to improve health financing in Morocco. However, the structure of financing has changed only slightly. Households still remain the main financer of health with a share of 45.6%, a drop of 5.1 points compared to the 2013 national health accounts [2]. This significant drop is explained, on the one hand, by the extension of medical coverage and, on the other hand, by the expansion of the list of reimbursable drugs, the promotion of generic drug prescriptions, and also the reduction in drug prices since 2014.

According to the latest national health accounts for 2018, collective and solidarity financing reached 53.3% in 2018 [2], exceeding 50% for the first time, compared to 46.8% in 2013. The improvement in solidarity financing constitutes a positive trend toward financial protection for the population, especially the most vulnerable groups.

However, despite this decline in out-of-pocket payments by households, the level recorded is still high by international standards.

To ensure equity and equality in the field of health, there is a fundamental step that a country can take, which is to move toward universal coverage. This means providing the population with social protection that allows them to have universal access to all the services they need. Whether universal coverage is financed by taxation, organized on the basis of a social insurance system, or both, the principles are the same: pooling of contributions paid in advance and using these funds to ensure accessible benefits and quality care for those who need it without exposing them to catastrophic costs.

Morocco has started the reform of health financing by adopting law n° 65–00 on the code of basic medical coverage with two schemes whose objective is to consolidate and converge all actions toward the common goal of universal health coverage. The aim is to consolidate and converge all actions toward the common objective of universal health coverage, thus ensuring equality and equity in access to care for the entire population without causing financial difficulties for users.

The first of the two schemes is a compulsory health insurance scheme for public sector employees and private sector employees, based on the principles and techniques of social insurance for the benefit of gainfully employed persons and pensioners. The second is a medical assistance scheme for the economically deprived, based on the principles of social assistance and national solidarity for the benefit of the deprived population.

The aim is to provide universal health care coverage, either through taxes or through social health insurance, so that households do not have to pay out of pocket for care when they need it.

The current organization of the Moroccan health system has several difficulties preventing the smooth progress toward universal coverage that need to be addressed to ensure equitable access and treatment for all people. What then are the obstacles and difficulties encountered by the health system, and what are the accompanying measures undertaken to accompany the redesign of the Moroccan health system?

2. Are we talking about a recast and not a reform

The royal speech of His Majesty Mohamed VI in 2018 had raised two points: The first is the rectification of the anomalies that mar the implementation of the health coverage program for the economically deprived, and the second is the in-depth overhaul of the national health system characterized by glaring inequalities and poor management.

Before talking about the path toward the achievement of universal coverage and the overhaul of the health system in the context of this achievement, we must recall an ideal health system. The health system is the set of human, material, and financial resources, institutions and activities designed to ensure the promotion, protection, restoration, and rehabilitation of the health of the population. Financial activities go beyond health care (inpatient and outpatient) and medical goods to other health-related sectors, namely education, hygiene, community health prevention, and research.

Such a system must first of all be comprehensive, allowing for a global care of users with curative but also, and above all, preventive care, rehabilitation, and health promotion. Secondly, it must be geographically and economically accessible, that is, closer to the patient, and cost must not be an obstacle. Third, it must be technically and economically efficient. Fourth, it must be acceptable to the population with legitimate expectations. Fifth, it must be measurable and assessable, that is, easy to predict and measure via health indicators. Finally, it must be flexible and modifiable, with the capacity to adapt quickly in the event of the emergence of new needs. We have seen the vulnerability of health systems around the world. The most telling example is the Italian system, which has almost collapsed under the flow of patients. It has shown its inability to provide intensive care or resuscitation for all patients, forcing them into painful and difficult choices. All health systems around the world were overwhelmed by a common problem: They were unprepared and not resilient enough to cope with a massive influx of patients in a pandemic context.

Numerous reforms have been undertaken over the years, and several advances have been recorded, such as the vaccination program, mother and child health, the surveillance of communicable diseases, the eradication of certain diseases, free childbirth, and even the addition of an additional subsidy to public hospitals to compensate for the shortfall in hospital revenue, among others.

At the same time, Morocco has been on the road to universal health coverage since 2002 with the adoption of law n°65–00 on the Basic Medical Coverage (BMC) code. The first scheme implemented in 2005 was the Compulsory Health Insurance (CHI) for employees and pensioners in both the public and private sectors.

Subsequently, the basic medical coverage project continued with the launch of the pilot experiment in 2008 and the generalization in 2012 of the Medical Assistance Scheme (RAMED) for the benefit of the underprivileged population, followed by the entry into force of the compulsory health insurance for students in 2016, the adoption of the law relating to the compulsory health insurance for non-salaried workers in 2018, and the gradual publication of its implementing decrees (Table 1).

Population	Distribution
Population: National Fund for Social Welfare Organizations	8.8%
Population: National Health Insurance Fund	21.01%
Students: National Fund for Social Welfare Organizations	0.7%
Medical Assistance Scheme	30.5%
Population 114	4.4%
Royal Armed Forces Mutual Fund, Former Resistance fighters and others	4.6%
Total population coverage	70.2%

Table 1.

Distribution of the Moroccan population covered according to the mode of coverage.

Source: Department of Planning and Financial Resources, compiled by the author.

This process, crowned by the adoption of the framework law n° 09–21 relating to social protection, has made it possible to increase the rate of basic medical coverage of the Moroccan population from 16% in 2005 to 70.2% in 2020, that is, 25.2 million beneficiaries (all schemes combined), of which 11.17 million are the compulsory health insurance beneficiaries and 11 million are the Medical Assistance Scheme beneficiaries [3]. The goal is to reach 100% of the Moroccan population, through the integration of 11 million self-employed workers and 11 million current Assistance Scheme beneficiaries who will switch to compulsory health insurance (a total of 22 million citizens), before the end of 2022. They will have insurance covering the costs of treatment and hospitalization. The new distribution of the Moroccan population according to insurance bodies will be presented as depicted in Table 2.

National Fund for Social Welfare Organizations (10%)	National Health Insurance Fund; (90%)
Public 3.20 million Population 114 0.26 million Students 0.23 million	Private 7.6 million Population 114 1.3 million Non-salaried workers 11 million Medical Assistance Scheme 11 million

Table 2.

Breakdown of the Moroccan population according to health insurance funds.

Source: Department of Planning and Financial Resources, completed by the author.

Moreover, despite the efforts made, citizens continue to suffer from the many limitations of the current national health system. This transition has not prevented deep social and territorial divides from widening. It is true that the results of the National Population and Family Health Survey in 2018 revealed a significant reduction in the maternal mortality ratio, which fell to 72.6 maternal deaths per 100,000 live births from 112 in 2010, a reduction of 35%, and a reduction in the neonatal mortality rate, which fell from 21.7% per 1000 live births in 2010 to 13.6% in 2018, a reduction of 37%. Nevertheless, these results remain fragile as there are still remarkable differences between the data related to residence and welfare quintiles, hiding inequalities and inequities between groups of people and territories: The maternal mortality ratio is 44.6 deaths/100,000 newborns in urban areas and 111.1 deaths/100,000 newborns in rural areas [4].

3. Challenges to the Moroccan health system

To give an idea of the challenges to be met, Morocco has been ranked by the United Nations at the 110th place in terms of health system performance and 111th place in terms of equity.

The results of the Medical Assistance Scheme for the benefit of the underprivileged population, which was generalized in 2012, have not lived up to expectations, with delays in diagnosis and consultation appointments.

Almost a quarter of RAMED card patients who were supposed to receive free public health care are turning to private health care, with the risk of falling below the poverty line due to catastrophic health care expenses. And more than 90% of health expenditure is incurred in the private sector.

The public sector is only used by patients who do not have medical coverage or people on medical assistance, which leads to the impoverishment of hospitals with a loss of revenue for the latter. Added to this is the fragmentation of health information systems.

The average occupancy rate (AOR) of public hospitals varies from 35–67%, with an average of 62% [5], which means that almost 4 out of 10 beds are empty. In the private sector, this rate exceeds 85%.

In addition, there is a shortage of human resources, with poor distribution and low retention and motivation of staff in remote areas. The number of doctors is only 7 per 10,000 inhabitants, which is below WHO standards, which recommend 23 doctors per 10,000 inhabitants. It is even lower than in neighboring Maghreb countries, with a ratio of 13 doctors per 10,000 inhabitants in Tunisia and 17 doctors per 10,000 inhabitants in Algeria.

The average productivity of surgeons is 166 operations per year, that is, one operation out of two. As for specialist doctors, they make 789 consultations per year, which corresponds to 3.2 consultations per day. This productivity is never indexed only to the health personnel, the whole system which makes that even if this personnel stays in the hospital for 24 hours, and you lock them up, the working conditions in the public hospital which go from stretcher bearer, the elevator which sometimes breaks down, the unavailability of the operating room. All this means that the number of possible interventions in the public system by the number of public doctors automatically gives us this failure. However, we have today a recognized competence, that our Moroccan doctors are recruited abroad.

The budget of the Ministry of Health and Social Welfare represents only 5.8% of the general state budget, which is still insufficient by international standards. The Abuja Declaration and the World Health Organization (WHO) specify that the state should devote 15 and 12% of its budget to the Ministry of Health, respectively.

Preventive care accounts for only 5% of current health expenditure. Knowing that a health system not based on primary care consumes a lot of budgets, human resources, and infrastructure, for poor results.

The last revision of the national reference rate (NRR) for the reimbursement of drugs and medical procedures dates back to 2006, creating a gap between practitioners’ fees and the reimbursement scale that is constantly widening and aggravating the co-payment remaining at the expense of the citizen. Normally, this national reference rate should be revised every three years. In addition, the patient must pay the co-payment, even for those with long-term illnesses. Normally, reimbursement is made differently, depending on whether it is an originator or a generic drug, as follows (agreement between the National Health Insurance Agency, the National Fund for Social Welfare Organizations, and the National Social Security Fund):

• In the absence of a generic drug, the originator is reimbursed according to its purchase price;

• Any generic drug is reimbursed according to its own price;

• In the presence of one or more generics, the reimbursement of the originator is based on the closest generic in terms of purchase price.

Generally, the reimbursement is 80% for the National Fund for Social Welfare and 70% for the National Social Security Fund.

If the beneficiary has applied for a long-term illness (LTI) that has been accepted by a medical examination, he or she will be recognized as having an LTI and will benefit from an advantageous rate, which is 100% for members of the National Fund for Social Welfare Organizations. For members of the National Social Security Fund, this rate is 90% if the service is provided in public hospitals and 85% if it is provided in private hospitals.

For analyses, the reimbursement is 80% for the National Social Security Fund even in the case of LTI and 90% for the National Social Security Fund if the service is provided in the public sector; otherwise, it is 85%.

The drug policy poses a major problem for the health system. The first contact of the Moroccan citizen with the health system is the pharmacy because it is closer and allows him to save a medical consultation. The public selling price (PSP) applied in private pharmacies is set by the Directorate of Medicines and Pharmacy (DMP) according to the benchmark method with seven countries (France, Spain, Belgium, Portugal, Saudi Arabia, Turkey, and the country of origin). This method identifies the cheapest public selling price among the seven countries as mentioned in article 3 of the pricing method of the official bulletin No. 6214–15 Safar 1735 (19-12-2013).

$$\begin{array}{l}PSP\left(Publicsaleprice\right)=Manufacturer’spriceexcludingvalueaddedtax\\ +Dispensarymargin+Distributor’smargin+Valueaddedtax\end{array}$$

These benchmark countries do not have a similar economic level as Morocco (not the same purchasing power, not the same gross domestic product, etc.)

According to the latest national health accounts of 2018, 45.6% of health expenditure is borne by households, to which must be added 14.1% of medical coverage [1]. In France, they are at 8%, and in Canada and Sweden, they are at 1%. However, despite a drop in direct payments by households compared to previous years, the level recorded is still high compared to internationally recommended standards of less than 25%.

4. Universal coverage: Out of reach or feasible

The question that arises, and which deserves careful consideration, is the following. How will a health system, already marked by numerous failures, be able to absorb 22 million new beneficiaries in order to achieve medical coverage for 100% of the Moroccan population by the end of 2022?

Certainly, with the integration of almost all Moroccans into this system, the system will be faced with an unprecedented increase in demand. This project is worthy and commendable, but it risks being a missed opportunity if we do not change the paradigm, governance, and overall organization of our system upstream to make it more equitable and efficient.

4.1 Accompanying measures

Indeed, Morocco, through the framework law 09–21, has undertaken an overhaul of its health system, based on various accompanying measures:

• First of all, the upgrading of public health care structures, in order to improve the attractiveness of the public hospital so that it can attract not only holders of the medical assistance card but also insured persons.

• The development of public–private partnerships remains unavoidable in order to succeed in this project. The private sector is very active and also heavily involved in the development of infrastructure, in the production of medicines and health technologies, and in their supply. In general, the public sector is overwhelmed by demand, while supply does not follow, hence the importance of mobilizing all resources, whether public or private, in order to rehabilitate hospital supply.

• The strengthening of prevention, early diagnosis, and primary care programs and the revision of the hospital management system with administrative and financial autonomy and an internal and external audit system.

• Efforts to recruit train and improve the working conditions of health staff.

• The introduction of a new governance of the health system with the territorial health grouping. The pilot experiment has already been launched in the Fez-Meknes region in northern Morocco. It is a medical and health care strategy implemented within a territory and serving patient care like the Territorial Hospital Grouping in France. The territorial health grouping is a regional steering instrument that defines the distribution of medical and paramedical resources in the regional territory and the way they are used. It is therefore a tool for reorganizing the supply of care, the aim being to optimize the availability and pooling of human, material, and financial resources between networks and care channels from the ambulatory structures up to the tertiary level; that is, these resources will be put at the service of the population in a territory that creates centers of excellence and not at the level of the structure.

• This territorial grouping requires the creation of an autonomous regional health establishment capitalizing on the university hospital center. The latter will absorb all the regional health establishments to become the leader at the regional level, and its main mission will be to manage all the health establishments and to implement the health policies of the Ministry of Health and Social Protection at the regional level. This means that all 12 regions of Morocco must have a university hospital center; for the moment, the country has only five functional university hospital centers in Casablanca, Rabat, Fez, Marrakech, and Oujda, in addition to three under construction in Tangier, Agadir, and Laâyoune.

• The overhaul of the institutional architecture of the public health system with the transition from a pyramidal system by level to a system of channels and care paths.

• Changing the status of staff and introducing new innovative incentive models such as capped fee-for-service and capitation payments.

• Despite the level of reimbursement, even in the case of long-term conditions, the remaining costs for patients are still high. The revision of the national reference rate is crucial to get closer to the real expenses.

• With a view to harmonizing the effective coverage by the health insurance funds, raising the awareness of the various parties involved (doctors, pharmacists) with regard to the revision of the protocols and therapeutic schemes validated for reimbursement is decisive. In addition, pharmacists should be encouraged to adhere to the third-party payment agreement between the National Health Insurance Agency, the health insurance bodies, and the federation of pharmacists in order to avoid partial reimbursement of medicines after the fact.

• Advocacy for the reduction of drug prices is a big work and awareness that must be done in this sense on the reduction of public selling prices. The Ministry of Health and Social Protection must apply law 17–04, obliging pharmaceutical laboratories domiciled in Morocco to market their medicines after obtaining marketing authorization while respecting the regulatory deadlines. In other words, laboratories that choose to set up in Morocco because of the country’s political stability or the cost of labor and to market their medicines abroad must respect the regulations in force after obtaining the marketing authorization given by the Department of Medicines and Pharmacy.

• Introduction of hospital billing within the hospital, similar to what is done in private pharmacies for magistral preparations in order to reduce the hospital bill.

• Funding autonomy based on the health insurance scheme with a total billing model and the introduction of an integrated information system.

4.2 Other challenges

As financing health from traditional tax revenues is not sufficient to meet the needs of the population, effective resource mobilization through increasing the health budget remains necessary. In addition, the rationalization of the use of available resources and the adoption of new financing mechanisms such as the taxation of products harmful to health, increased taxes on airline tickets, foreign exchange transactions, and private services such as telecommunications are already being progressively implemented [6].

Other challenges remain to be met in order to succeed in this project, namely the revision of the national reference tariff, the nomenclature of professional acts and therapeutic protocols, the revision of the pricing policy, the local manufacture of generics, etc.

In addition to the other challenges, the list of reimbursable medicines needs to be further expanded. For medicines that do not yet have a marketing authorization (MA), the pharmaceutical company concerned must obtain an MA, the public selling price (PPV), and the hospital price (PH), which are set by the Ministry of Health and Social Protection (MHSP) through the Department of Medicines and Pharmacy. Afterward, it applies to the National Health Insurance Agency (NHIA) for reimbursement of the drug.

The list of medicines selected for reimbursement is drawn up by commissions composed of representatives of the MHSP, the health insurance funds, and the NHIA, on the basis of the medical service rendered (SMR) of each medicine. The Transparency Commission (CT) gives the MHSP an opinion on the SMR of a medicine that has already obtained a marketing authorization, with a view to its inclusion or removal from the list of reimbursable medicines.

In order to strengthen the criteria for the reimbursement of medicines, the NHIA has created the Commission for the Economic and Financial Evaluation of Health Products (CEFHP). The latter decides on all applications concerning medicines, by analyzing the economic and financial impact of medicines that have been given a favorable medical service by the CT. This commission decides on all applications concerning medicines, by analyzing the economic and financial impact of medicines that have been given a favorable medical service by the CT.

Can addressing these challenges and the profound overhaul of the national health system make the system more efficient and equitable? In other words, is there a perfect health system?

5. Good health system: Does it exist or not?

The only clear and indisputable evidence is that there is no such thing as a good health system; such a system would be one that manages to connect the four poles of a magic square as shown in Figure 1.

Figure 1.

Source: Chakib Boukhalfa 2022.

First is through the achievement of medical efficiency with better medical outcomes, sound research programs, and good quality of care. The United States is a very good example of medical efficiency, winning more than half of the Nobel Prizes in Medicine, making it the most innovative country in the medical field. Add to this the fact that continuing education for doctors in the United States is mandatory in all 50 states and doctors have to revalidate their degrees regularly, but what about solidarity and fairness?

Added to this is the control of expenditure with technical and economic efficiency, linking the labor and capital factor with the contribution to the production of care and the improvement of health status with costs.

Secondly, the preservation of solidarity with a mutualization of risks, that is, the healthy pay for the sick, the active pay for the passive, and the young pay for the elderly.

And finally, there is equity, with the assurance of vertical equity, that is, people should pay different amounts, depending on their ability to pay, and horizontal equity, that is, people should be treated in the same way if they have a similar problem, regardless of their social or geographical origin. France is a good example, but until when.

It is clear that no health system can claim to have the perfect formula, in terms of both equal access to quality care and economic efficiency. Experiences have revealed many flaws within the different health systems, especially in relation to inequalities and inequity [7]. This calls for a project to reform the whole system for better performance.

6. Conclusion

The health problem is a multi-sectoral problem that requires the federation of efforts of all actors and not only the Ministry of Health and Social Welfare. As mentioned in the 1982 Organization for Economic Co-operation and Development report, “Improvement in health status depends on 20% of the health system; the remaining 80% are the external determinants of the system.”

To conclude, we could not find a better excerpt from the royal letter addressed to the participants in the celebration of the World Health Day: “Universal health coverage is not an unattainable goal, just as it is not the prerogative of advanced countries alone. Indeed, many experiences have shown, in a tangible way, that this objective is perfectly achievable, whatever the level of development of a country.”

As mentioned in the royal letter, the dream of generalizing medical coverage in any country can become a reality. In order to achieve this in its current state, specific efforts must be made, especially in the area of reducing the price of medicines and changing the governance and overall organization of our system. In general, the planning of this project must be carried out on an ongoing basis. Other awareness-raising and accompanying actions must be designed in advance to guarantee the progress made to date and to make the system even more equitable and efficient.