Morocco offers an opportunity to study the health system of a lower-middle-income country in the Middle East and North Africa region that, despite some unique features, has numerous similarities to many developing countries. Morocco has made major improvements in developing its health system capacity and dealing with communicable diseases over the past three decades, resulting in dramatic improvements in health status. Despite these trends, however, gaps in health status, access, utilization, quality, and financial protection exist between the rich and poor and between urban and rural areas.
Although the government recognizes its responsibility for indigent people and provides public health and clinical care for the poor in public facilities, inadequacies pervade the system. There are limited resources to cover basic and specialized care. The pattern and level of resources (human, financial, and physical), the scarcity of providers and basic clinic and hospital facilities, along with limited quality in facilities and providers, all contribute to difficulties in meeting the population's health needs. One of the most important problems is the system of insurance coverage for public-sector employees, coupled with the lack of financial protection for 84 percent of the population.
Morocco is implementing reforms to improve the efficiency and quality of care provided in selected hospitals, decentralize service provision, improve information systems, and rationalize future hospital investments and management. Reforms seek to rectify key problems by allocating more resources to essential preventive and curative care for the poor and those in rural areas, and strengthening the safe motherhood and priority public health programs.3
RAMED aims to improve coverage for the poor, to better match needs with usage patterns.
Questions arise, however, as to the likelihood of success and potential effects of both AMO and RAMED. Will reforms produce positive results? It depends.
■ Financial challenges
First, for financing, the government of Morocco must be able to greatly increase the amount of public resources devoted to health care to expand coverage, meet the population's health demands, and broaden the scope of the benefit package. Morocco spends 4.5 percent of GDP, or US$50, per capita on health care, but roughly half of that funding comes from direct payments from households (net of reimbursement from mutuals or insurers), whereas only 5 percent comes from employees’ contributions to insurance. Moreover, poorer households spend a higher percentage of income than wealthier households. To obtain sufficient financing for reforms, the government must not only raise additional funds but must also shift funding sources, by reducing funding from households and increasing funding from employers and the government.
■ Distribution of public resources
Second, the government will also need to change the distribution of public resources among regions, populations, and providers and provide a guarantee for financial commitments to local authorities, especially in rural areas. Policymakers will need to overcome vested and inequitable allocation patterns, especially among providers, which now leave the MOH with only 27 percent of the resources raised by the health system, despite its role as the major provider of services. Current insurance spending focuses primarily on pharmaceuticals, medical goods and devices, and services provided in private offices and clinics. For reforms to succeed, especially RAMED, resources for MOH facilities and personnel—especially expansion to rural areas—must be sufficient.
■ Institutional fragmentation
Finally, the government must streamline and integrate institutional fragmentation. In the absence of an overall risk-pooling mechanism, Morocco's voluntary insurance structures have been subject to risk selection and segmentation. To pool and adjust for risk across populations, the government will need to promote the integration of public and employer-related financing sources and social security and regulatory agencies. Reforms must combine the current division of functions and funding streams between the CNOPS and the public mutuals and the fragmented and decentralized risk pools.
The moroccan health system has improved dramatically over the past several decades and has achieved major milestones in health status, health care delivery, and financing. Despite these considerable gains, however, health system weaknesses reveal inequities and inefficiencies in both access and financing. To rectify these limitations and build on the strengths of the current system, the Moroccan government is implementing major policy reforms. These laudable efforts offer hope for closing health system gaps in Morocco and lessons for both developing and developed countries worldwide.