Morocco is currently implementing the most ambitious, far-reaching, and comprehensive health system reorganizations in its history. “What sets this reform apart from all that has happened before is just how starkly it differs in spirit from previous incremental and piecemeal initiatives that have been attempted over the decades,” proudly asserts Khalid Aït Taleb, the country’s Minister of Health and Social Protection.
“Never in the history of our national health system has there been such a sustained and vigorous commitment to addressing social disparities and guaranteeing uniformity of access to vital services… This time we’re seeing an irreversible, transformative shift that blazes new trails by placing Moroccan citizens at the forefront, reinforcing their rights, and emphasizing importance of healthcare sovereignty,” he affirms.
The past two years have certainly witnessed a watershed moment in the development trajectory of Moroccan healthcare with the remarkably speedy roll-out of universal health coverage nationwide. In December 2022, the country took the historic step of transitioning over to a new mandatory healthcare regime (the so-called Assurance Maladie Obligatoire or AMO) designed to plug coverage gaps and enable healthcare for all from cradle to grave.
The first pillar of this program, AMO-TNS, caters to non-salaried workers, including farmers, traders, and artisans. The second, AMO-Tadamon, which translates roughly as ‘solidarity,’ targets vulnerable populations identified through a freshly established ‘Unified Social Registry.’ Under that new system, the government covers insurance premiums for those individuals, ensuring that they receive exactly the same level of healthcare coverage as salaried workers.
Never in the history of our national health system has there been such a sustained and vigorous commitment to addressing social disparities and guaranteeing uniformity of access to vital services
Khalid Aït Taleb, Minister of Health and Social Protection
“This landmark reform aims to provide comprehensive protection to all Moroccans, prioritizing those with the greatest needs, while eschewing any kind of multi-tiered system with different levels of coverage according to class or social status which tends to be the norm in this part of the world,” proclaims Hassan Boubrik, director general of the National Social Security Fund (CNSS).
Meanwhile, the great advantage of the Unified Social Registry is that it allows, for the very first time, for precision means-testing and targeting through the allocation of objective, verifiable, and entirely rational scores. “Based on the score calculated and assigned, if you are below the threshold, the government is automatically obliged to covers your contributions,” explains Boubrik.
This is a big deal because it means AMO-Tadamon support now extends to approximately four million insured individuals which then scales up to around ten million people once beneficiaries, such as spouses and children, are taken into account: tantamount to more than a quarter of Morocco’s entire national population. “When you think back to the end of 2020, it’s frankly astonishing to consider the massive leap forward that has occurred within such a brief timeframe,” enthuses Pierre Labbé, general manager of Maphar and CFAO Healthcare Maghreb.
“Back then a mere 40 percent of the Moroccan population was covered with health insurance, private or public, with an additional 30 percent having to make do with a limited scheme for the poor called RAMED, which was not an insurance as such, but rather a coverage assistance – one that only operated only within the confines of the public sector and almost always entailed considerable waiting times,” he recalls.
“This is certainly a gamechanger for many people especially the indigent who were previously ascribed to the RAMED system or left unserved,” agrees Layla Laassel Sentissi, executive director of the Moroccan Federation of Pharmaceutical Industry and Innovation (FMIIP), “because, all of a sudden, they have gained the possibility to consult on an outpatient basis in the private sector and to access high-quality levels of treatment in a timely manner.”
“There can be absolutely no doubt that this is a dramatic advancement for our country in terms of social progress, especially when you consider that there were previously great swathes of the population with zero access to medical consultations or medications, and who lacked the purchasing power to afford care,” agrees Mohamed El Bouhmadi, president and CEO of Zenith Pharma.
Boom Time for Pharma
The implications are also significant for the future performance of the country’s life science sector. “Whereas today, Morocco ranks the fifth largest pharma market on the African continent – behind Egypt, Algeria, South Africa and Nigeria – within the next three years we’re expecting it to surge to fourth spot, with market turnover projected to surpass USD 2.1 billion,” predicts Labbé, noting that all this makes for a “highly exciting and auspicious time to be involved in the local pharmaceuticals business.”
Indeed, among the windfall of opportunities to be grasped is the opening up of the ‘patient reservoir’ with upwards of 22 million additional Moroccan citizens now destined to be added to the existing 14 million already benefiting from medical coverage.
“This blanket generalization of coverage can be paradigm-shifting from the point of view of market access prospects for drug developers,” reasons Adrien Delamare-Deboutteville, country manager for general medicines at Sanofi, “It means our therapies could potentially reach a far larger cohort of patients than was previously the case and brings new hope to the many Moroccans out there with unmet or underserved needs.”
This blanket generalization of coverage can be paradigm-shifting from the point of view of market access prospects for drug developers
Adrien Delamare-Deboutteville, Sanofi
The FMIIP’s Layla Sentissi very much concurs. “Our members are eagerly awaiting details on how the government plans to define the care package, especially regarding therapeutic protocols… They are keen know the list of essential drugs considered so that they can adapt and invest in the appropriate areas with a view to capturing the many new opportunities that are presently unfolding,” she observes.
One such member is Anthony Lauw, general manager of human pharma for Northwest Africa at the German innovative drug developer Boehringer Ingelheim. “My team is keen to understand how much of this ambition will be dedicated towards opportunities in life science innovation and continued investment in research-based sectors, as scientific discovery has the potential to truly transform the lives of Moroccan patients,” he admits.
More likely, however, is that it is the local manufacturers rather than multinational originator drug developers who stand to gain the most with the Moroccan state organs and insurance bodies likely having to resort to generics and biosimilars to control spending as they deal with the upswell in new patients requiring treatment.
“If our authorities are willing to fast-track biosimilars and generics, there is a massive opportunity to lower drug costs: The more we produce locally, the more we fit into the system and help fund the ongoing transformation,” reasons Mia Lahlou-Filali, CEO of the family-owned homegrown drugmaker Pharma 5, which already represents one third of the domestic generics market and ranks as a leading supplier of Moroccan hospitals. “The stakes are tremendously high, and it is imperative that medicines be made available to the Moroccan people at an ethical price,” he argues.
Other industry insiders, though, are quick to push back against any temptation to make pharmaceutical companies shoulder the lion’s share of any future cost-containment drives. “We should not fall into the trap of assuming that medication, as is often erroneously implied, constitutes the main component that will ensure the sustainability of universal health coverage,” counsels Zenith Pharma’s El Bouhmadi.
“As of today, pharmaceuticals are accounting for only around 28 percent of total healthcare expenditure, so we should not solely focus on reducing the price of medication to the maximum extent… By doing so, we could end up with medicine shortages with needed products vacating the market. Far better, to keep in sight the bigger picture and always seek a balanced and equitable approach,” he advises.
Proceeding At Full Throttle
What, then, has been the impetus for such a profound transformation? Many observers note that the urgency of reform was underscored during the COVID-19 global pandemic which exposed frailties within the national care apparatus and social security safety net, while simultaneously magnifying the benefits of securing greater sovereign control over matters of public health and wellbeing.
Others see it more within the framework of 2030 Visions that have become commonplace across North Africa and the Middle East as a long-overlooked and often somewhat marginalized region finally reaches maturity and comes of age.
In reality, the decision to opt for radical reorganization was actually taken long before. “The crisis highlighted the vital importance of self-reliance and control during public health emergencies, but His Majesty Mohammed VI resolved upon a root and branch level of reform back in 2018, significantly predating the emergence of the virus,” confirms Aziz Mrabti, director general of the Medicines and Pharmacy Directorate (DMP) of the Ministry of Health, though he concedes that “the pandemic played a pivotal role in expediting and accelerating the pace and scope of implementation.”
Indeed, far from being a one-off, flash-in-the-pan initiative, the quest for universal health coverage is part of an intricately planned and thought-out program to reinvent and reimagine Morocco’s public health offering. “Significant resources have been mobilized to support this generational healthcare reform: encompassing, among others, the rehabilitation of primary care facilities nationwide, the building and equipping of university hospitals, a new regulatory apparatus, pensions overhaul, and localization of life science capabilities,” points out Fadela Benjelloun, executive director of LEMM, an association of multinational R&D-driven pharma companies operating in the country.
The [COVID-19] crisis highlighted the vital importance of self-reliance and control during public health emergencies, but His Majesty Mohammed VI resolved upon a root and branch level of reform back in 2018, significantly predating the emergence of the virus
Aziz Mrabti, Medicines & Pharmacy Directorate (DMP)
Universal healthcare coverage is merely the starting point, not the ultimate goal,” confides Minister Aït Taleb. “This government made it our mission to create a protective shield for our people and address any vulnerabilities in a holistic manner. Within our social protection framework, we have identified four key components – medical coverage, family allowances, retirement benefits, and unemployment support – and we will not rest until this complete package of welfare is available to all,” he insists.
“Throughout 2024, we have been tasked with extending family allowances,” confirms the CNSS’ Hassan Boubrik. “Following that, in 2025, we plan to introduce universal retirement and unemployment benefits, which translates to enlarging the membership base of the national pension scheme to include nearly five million people who are in employment but presently outside any scheme,” he adds.
Fresh Governance
Meanwhile the push towards universality has unleashed all manner of associated regulatory and structural changes, starting with a brand new governance model. “Our agency has been assigned an important role as the sole regulatory authority for compulsory health insurance,” confides Khalid Lahlou, general director of the National Health Insurance Agency (ANAM).
“Our responsibilities encompass a broad array of aspects, including ensuring that the objectives of health insurance remain in line with the strategic orientations of the national health system, monitoring the financial balance of the funds managing the programs, as well as developing standards, regulatory and technical tools aimed at reinforcing access to quality care at the right cost,” he reveals.
Most importantly, the agency has been tasked with coordinating and maintaining synergies of action between the diverse stakeholders involved in the newly established universal healthcare ecosystem: notably the insurers, care and service providers, local authorities, and the pharma industry, as well as the end beneficiaries. “This arbitration mission is perhaps the most tricky task of all and will require astute collaboration, goal-setting along with controlled, targeted investment,” muses Lahlou.
Ahmad Almwakeh, country manager at Merck very much agrees, drawing attention to the sheer complexity of processes and actors involved: from means testing and procurement, to financing and managing the flow of patients. “Fashioning a robust and fit-for-purpose regulatory framework with clear accountability and demarcation of responsibilities is an absolute pre-requisite for being able to successfully fulfil the stated ambition of equitable access to healthcare for all Moroccans,” he posits.
To assist with some of these items, a brand new ‘High Health Authority’ is being provided for in law with a view to playing a central role in enhancing the health insurance regulator’s capabilities by focusing on areas such as quality assurance, continuing education, accreditation and public health priorities.
“Once established, this High Health Authority should be a valuable resource for strategic health planning, upholding standards, and assistance with policy alignment,” expects Lahlou.
Strategic Regionalization
At the same time, the predicted upswell in demand for treatment inherent to universal coverage has been triggering a rethinking of the nation’s healthcare apparatus and the manner in which care provision is to be organized.
For instance, a Council of Ministers held in early 2023, and presided over personally by King Mohammed VI, resolved to increase the number of health professionals by 90,000 by 2025, with 45 health professionals for every 10,000 inhabitants by 2030, and new rules of the game entering into force for overseas healthcare providers willing to invest in Morocco.
To reach these goals, considerable efforts are being made to upgrade, rehabilitate, and improve the existing medical faculties, and 3 new university hospitals shall be opened in Errachidia, Beni Mellal and Guelmim respectively, to the tune of almost 300 million dollars, while the duration of medical training will be reduced from seven to six years.
Concurrently, twelve new medical centers are set to be inaugurated in different cities of the Kingdom: with three in Casablanca, two in Fez and Tangier respectively, and one in each of the cities of Agadir, Marrakech, Rabat, Sale and Temara. Moreover, the government has removed legal barriers to investment with a view to enticing foreign companies to start participating in Morocco’s healthcare system with additional tax incentives and state aid on the table for any foreign healthcare providers willing to work in under-served so-called ‘medical deserts.’
Most eye-catching of all, new territorial health groups are to be created which will be afforded the flexibility to engage in public-private partnerships, both domestically and internationally, and access international resources. “The objective here is to foster competition among regions and recognize their unique characteristics, resources, and healthcare needs,” details Minister Khalid Aït Taleb.
“Each region will be permitted to develop its own regional health policy, resulting in a regional health plan. This plan will help identify investment needs, human resources requirements, and the specific healthcare needs of the population, tailoring the healthcare approach to each region’s distinct situation,” he explains.
Hospitals that offer high-quality services will receive more resources. This competition encourages better performance and quality of service in both the public and private sectors
Hassan Boubrik, National Social Security Fund (CNSS)
“The generalization of mandatory health insurance is crucial because it fosters competition among different healthcare facilities, particularly within the public sector. For instance, public hospitals are traditionally guaranteed budgets by the government, regardless of their performance. However, with a significant portion of financing now coming from social security, patient choices will suddenly play a vital role,” opines the CNSS’ Hassan Boubrik.
“Hospitals that offer high-quality services will receive more resources. This competition encourages better performance and quality of service in both the public and private sectors. Additionally, allowing beneficiaries of AMO-Tadamon to have a choice between private and public healthcare facilities is welcome because it encourages the public sector to improve its services and efficiency,” he thinks.
“For the private sector, collaborations between public and private entities within the framework of this reform aim to establish regional medical programs and regional health maps, giving priority to the territorial dimension in citizens’ access to care, to the widespread availability of medicines, and to a balanced geographical distribution of healthcare provision. This collaborative, partnership-based approach plays a central role in significantly upgrading Morocco’s health and health insurance systems, which are will, from now on, be highly interdependent and complementary,” concludes ANAM’s Khalid Lahlou.
Hard-wiring Financial Viability
Important question marks remain, however, about how Morocco is going to manage to fund obligatory health insurance for all in the long run without imperilling the national coffers. In 2023, the General State Budget allocated to health and welfare was already a full 13.8 percent higher than the year before, and, that same year, the country took out a USD 450 million Program-for-Results loan from the World Bank and signed joint-cooperation programmes worth USD 500 million from the European Union, all with a view to help financing the implementation of its ambitious health reform.
“The question that arises is how to satisfy this demand without ruining the funds managing the care system. When we talk about health insurance, the most important thing is allowing the Moroccan population to access healthcare, medicines, and healthcare products without financial barriers. To succeed in this, it is not enough in itself just to proclaim that we’ve achieved 100 percent coverage; we actually need to make it sustainable, or it will be all for nothing,” warns Aziz Mrabti of the Medicines and Pharmacy Directorate.
“Confronting these concerns about long-term financial viability is crucial because the future demographics of our nation are not stacked in our favour,” agrees Lahlou. “Just because today the CNSS enjoys a financial surplus accumulated over a considerable period doesn’t mean that it will always be that way, especially in the light of the exponential expansion in demand that has occurred over the past two years. Already we can anticipate clouds on the horizon” he warns. Moreover, he notes that these financing challenges don’t just affect the new coverage schemes, but equally apply those existing prior to the commencement of the reforms.
Take, for example, the National Fund of Social Security Organizations (CNOPS) health insurance scheme which covers around eight percent of the national population and is geared to mainly public-sector employees. This scheme is characterised by a strong culture of healthcare consumption, yet the pronounced ageing of its population – a worrying demographic ratio with only 1.6 employees for each pensioner – alongside the rising healthcare costs associated with technological advances in medical science and the newfound availability of costly innovative drugs mean that it is going to be difficult to balance the books in the future under a business-as-usual scenario. “These combined factors pose a major risk to the viability of the scheme, and urgently call for innovative financing instruments, new regulations, and cost-containment measures to redress the situation,” he argues.
As such, the CNSS has been busy working on ways to harness national reference pricing, through a new national agreement, with a view to ensuring equitable payment for quality care. “We are also actively setting medical and technical standards through therapeutic protocols, and entering into negotiations with the pharmaceutical industry, with the aim of optimising the high costs associated with some innovative therapies,” he confirms.
Meanwhile, the prevailing philosophy amongst the healthcare reform’s policymakers and administrators has revolved around the need for health insurance to be self-sustaining in funding the healthcare system.
“A deliberate choice has been made in Morocco to adopt a contributive model. This means that direct taxation isn’t the primary source of funding; instead, it indirectly supports the system. The state only foots the bill for vulnerable individuals, which are calculated at 6.37 percent of the minimum wage. For self-employed individuals, they are responsible for paying their own mandatory monthly contributions. The system, as it is currently structured, is therefore primarily based upon self-sustainment,” explains Hassan Boubrik.
Though he believes the state might still have to raise its own share. “Currently Morocco is spending around six percent of its GDP on healthcare, which could be perceived as a bit low compared to some of our peer countries. Ultimately, a slight increase, say, of one or one and a half percent could become necessary,” he thinks
“Our government has allocated substantial resources and now is attempting to establish a financing system that is both fungible and equitable, thereby ensuring a resilient healthcare system. At some point, financial resources must be tapped into. This involves contributions from third parties and a share from the government. But striking the optimum balance will be imperative,” agrees Aït Taleb.
Equally critical for the system to work sustainably will be that the healthcare system not only receives these bountiful resources, but also deploys them wisely and efficiently delivering value for money expended and offering services worthy of investment.
“In theory, the universal coverage system that has been designed shall elevate all healthcare facilities to a standard whereby every citizen, now regarded as a client due to their newfound solvency, will gain access to normalized levels of quality care. They will either pay directly or have an overseeing entity – their mandatory health insurance. This should foster an internal market of competing healthcare facilities with each hospital and clinic striving to provide the best services possible to attract a broad clientele and tap into additional revenue streams,” explains Aït Taleb.
Seeking Out a ‘Digital Dividend’
So as to transform theory into reality, many Morocco’s public health administrators are looking to digitalization and data-driven insights. “To head-off and mitigate a situation whereby healthcare expenses might reach an unsustainable level, we have been turning to Big Data to generate actionable insights,” reveals Hassan Boubrik.
“We are convinced that sound data management will be crucial for prevention, early and appropriate treatment, fraud prevention, and curbing unnecessary expenditures. Our aim is therefore to harness data-generated intelligence and predictive analytics to attain a 360-degree view of healthcare providers and our insured population. That way we should be able to monitor in real-time precisely what people are consuming and what healthcare providers are prescribing, so as to identify areas where efficiency gains can be made without materially compromising the health of citizens,” he elaborates.
Front and foremost in this endeavour has been the introduction of electronic medical records shared across the system between patients, payers and healthcare providers. “This will greatly facilitate the patient’s care journey within our system and provide all the necessary information for sound decision-making at the administrative level,” predicts Aziz Mrabti.
“Rationalized and efficiently administered health insurance simply isn’t possible without a robust information system in place. This is precisely why we have already taken it upon ourselves to roll-out a comprehensive information system with sharable medical records across all twelve regions, ensuring interoperability from primary to tertiary healthcare levels,” says Aït Taleb. At the primary level, this includes health centres and local hospitals; at the secondary level, provincial or regional hospitals; and at the tertiary level, university hospitals.
The Ministry of Health has simultaneously established an agreement with the General Directorate for National Security (DGSN) to incorporate a health identifier into the national identity card, which will include a medical history for each patient. “When the card is inserted into a reader, the information is readily available, eliminating the need for manual data entry. Furthermore, we plan to securely store this data within a sovereign cloud infrastructure to ensure data is kept within our jurisdiction and is non-tamperable,” he elaborates.
Staying the Course
Few people are under any illusion, however, about the many practical obstacles that lie ahead in enacting such a sizable and complex reform program. As such, there is a general acceptance that, in spite of the rapid progress and manifold successes attained to date, that patience and perseverance will still be needed to materialize the vision of high-quality, standardized health coverage that leaves no citizen behind.
“Moroccan citizens are beginning to gain this access, but we have not yet seen the full impact because everything has happened so fast that many patients are still not yet aware of the coverage they have been granted by the Moroccan state,” reflects Zenith Pharma’s Mohamed El Bouhmadi.
In his opinion, the roll-out so far has been rather lopsided. “The system is functioning well for more serious medical conditions and for fast reimbursement processes. However, when it comes to minor health issues, not enough people fully embraced the concept yet, so it will take a bit of time to properly bed-in,” he perceives.
Driss Chaoui, managing director of Afric-Phar, meanwhile, highlights some of the technical impediments to smooth implementation. “Many patients presently find themselves having to pay upfront for medications and seek reimbursement later, which can be a formidable obstacle for those unable to afford the initial cost. There’s a third-party payment system in place for some high-cost medications, but it’s currently not uniformly applied, leading to complexities in affordability and access,” he regrets.
Overall, however, the mood is one of unbridled optimism and positivity for the future with many stakeholders proud at the way in which Morocco has found the wherewithal and audacity to put in motion such sweeping and ambitious changes.
“This country has a history of setting precedents when it puts its mind to it as we have seen in both the automotive and aeronautics industries and my feeling is that healthcare is poised for a similar success story,” enthuses Hocine Mahdi, general manager for North, East and West Africa at IQVIA.
“My hunch is that, as Morocco progresses in healthcare, it will set the standard and benchmark for others across the region to follow, becoming a beacon that everyone will look up to. Other African nations will look toward Morocco and think, if they can achieve this, so can we, which is a great spot to be in and testament to the excellent happenings that have been taking place here,” he opines.
“The future is unquestionably bright,” agrees Fadela Benjelloun. “The return on investment in healthcare is clear; a healthier population positively impacts GDP so mandatory universal health insurance, so long as it is smartly executed, will bring cascade benefits – for patients, industry and the country. This is why we so wholeheartedly support it,” she concludes.
