Facing Parliament on June 13, the head of government Aziz Akhannouch presented the outlines of the major reform of his five-year term: that of health. While the generalization of social protection is well underway – the Compulsory Health Insurance (AMO) should cover nearly 22 million additional Moroccans by the end of the year – the State must prepare for a sharp increase of the demand for care.
Medical deserts, shortages of medical and paramedical staff, lack of infrastructure, poor governance, funding problem… The shortcomings of the Moroccan public hospital are numerous.
A size indicator bears witness to this: 90% of the financial resources mobilized by the AMO go to the private sector. Moroccans prefer to go into debt, or even impoverish themselves, to access the private sector rather than seek treatment in the public sector.
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The kingdom devotes 6% of its GDP to health expenditure, 25% of which is financed by tax revenues. More than 59.9% of health-related costs are borne by households. By 2035, the state wants to reduce this share, which weighs very heavily in the budget of Moroccans, to 30%.
Towards a regionalization of health?
This is why the government is proposing a total overhaul of the health sector articulated around three axes: the upgrading of infrastructures, governance and human resources.
On paper, the government has already designed a new organization of the offer health, the aim of which is to strengthen the local and regional medical network. The starting point for this restructuring, called Territorial Health Grouping (GST): Primary Health Establishments (ESP), intended for local care and “reference point” for patients for general medicine, paediatrics, obstetrics and intensive care.
Then come the Provincial Hospital Centers (CHP) called upon to also provide basic care and more specialized care (ophthalmology, intensive care), then the Regional Hospital Centers (CHR), positioned on regional or inter-regional medical specialties such as oncology or neurosurgery.
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At the top of the pyramid, the University Hospital Centers (CHU), which will have to both manage all the establishments dependent on a GST and carry out their main missions: development of expertise in several cutting-edge specialties, development of scientific research and strengthening medical training.
To oversee this entire chain, the government intends to create a High Authority for Integrated Health Regulation (HARIS), a super-structure, endowed with a High Commissioner and financial autonomy, responsible for implementing implementation and monitoring of the State strategy.
In this new organization chart, the Ministry of Health would only be a kind of intermediary between HARIS and the health actors. On the side of professionals in the sector, some already fear a “gas factory”, where bureaucracy and administrative executives would take precedence over medicine and nursing staff.
Concretely, the Akhannouch government has released an envelope of 6 billion dirhams (566 million euros) for the rehabilitation of infrastructure, including 1.5 billion dirhams allocated to the construction of two new university hospitals in Rabat and Laâyoune, and 3, 4 billion dirhams allocated to the construction or upgrading of CHP and CHR. At the end of 2021, the French Development Agency (AFD) had also granted a loan of 150 million euros to participate in this vast upgrading operation.
The human resources challenge
The other major project the government intends to tackle is that of human resources, undoubtedly the Achilles’ heel of the health sector. The report of the National Human Rights Council (CNDH) in April estimates Moroccan needs at 32,000 doctors in the public sector, whereas there are currently only 13,662.
“One in three Moroccan doctors practices abroad and Law 31-21 relating to the practice of foreign doctors in Morocco has attracted only 48 in the space of a year”, underlines the economist Abdelghani Youmni . The kingdom has only 7 doctors and 8 nurses and midwives per 10,000 inhabitants. The fault is a lack of financial attractiveness and sometimes difficult working conditions.
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A figure well below WHO standards, which estimates that below 23 health professionals per 10,000 inhabitants, the rate of healthcare coverage is insufficient. By 2035, the Morocco therefore aims to achieve a ratio of 45 caregivers per 10,000 inhabitants through three levers: salary increases (+ 350 euros on average by January 2023), easier access to medical studies and a training course reduced to six years instead of the current seven.
In the Maghreb, it is in the kingdom that doctors in the public sector are the best paid (about 1,100 euros on average per month, against 450 euros in Algeria and 365 in Tunisia). But a Moroccan intern earns less than 300 euros per month and around 800 euros at the start of his career when he is established, not to mention his arbitrary assignment in an area chosen by the State for several years (often remote or landlocked regions).
Moreover, “the training period of a specialist or a surgeon varies between twelve and fifteen years. Practitioners in the health system rarely have balanced private lives, a counterpart in income seems essential. A reflection on bridges of working time between public and private could partly resolve this legitimate thirst for earning a decent living”, believes Abdelghani Youmni.
The eternal problem of financing
This ambitious health reform also raises the issue of funding. On June 20, the World Bank granted a loan of 500 million dollars to the kingdom in order to support development policies, in particular those related to the resilience of the health system. However, structural reform and a sustainable system cannot be financed exclusively by debt.
The financing levers exist: reform of the tax base and reduction of the informal economy, for example. “To succeed in this proactive reform, the health financing base should be based on compulsory levies and not on quasi-voluntary contributions”, says Abdelghani Youmni. So far, the government hasn’t mentioned anything like that.
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Another possibility for the government: to rely on the crutch of the private sector. “We mistakenly believe that the state has lost control of health because of the private sector, but in reality it has lost control of social and territorial inequalities. For years, the private sector has bridged the gaps, as well as the lack of human and material resources of the public sector, especially in the north and south of Morocco,” says Youmni.
Currently, the private sector represents 356 clinics, 12,000 doctors and 9,719 beds, compared to 158 hospitals (and 2,000 health centers) and 23,000 beds for the public. “The public hospital wants to save money, the private benefits, but in any case, it is never free, it is the taxpayers and the contributors who pay.
For the health system to be effective and for this reform to bear fruit, public-private partnerships must be pursued, which, while replacing the budgetary effort of the public authorities in return for a rent, in principle make it possible to improve and to optimize the performance of health systems. In Turkey, the revolution of the health system has made it possible, between 2002 and 2020, and thanks to public-private partnership, to increase the number of health professionals by 36%, to reduce the cost by 35% for citizens, and to reach more than 176,000 beds”, argues encore the Economist.