The Moroccan National Social Security Fund (CNSS) has taken on a transformational mandate in recent years, spearheading the highly ambitious national campaign to expand universal health insurance to the entire Moroccan population. In a wide-ranging and in-depth conversation, CNSS Director General Hassan Boubrik lays out the scope and scale of this reform, issues of financing and human capital, and his broader hopes for the future of his country's healthcare system.
How did you come to head up CNSS?
I pursued my education in Paris, earning an engineering degree from the National School of Statistics and Economic Administration. After a brief stint in private-sector marketing, I transitioned to the public sector, notably at the Caisse de Dépôt et de Gestion where I held various roles, including General Manager of the Investment Bank and Secretary-General of the group. Subsequently, I was appointed to lead the Directorate of Insurance and Social Welfare at the Ministry of Finance. My career in the insurance and social welfare sector began in 2010.
In recent years, I took on the role of President of the Insurance and Social Welfare Control Authority before joining the National Social Security Fund, appointed to contribute to a nationwide social protection project following my nomination by His Majesty and the Council of Ministers.
Could you please provide us with some insight into the role of CNSS, the types of coverage it offers and through which funding sources, and what the guiding principles behind this coverage are?
CNSS, in its 60-year history, originally focused on providing coverage to private sector employees. Initially centred on pensions, its coverage expanded considerably. It later introduced additional benefits like death allowances, disability allowances, and subsequently family allowances.
In 2005, we introduced obligatory health insurance (AMO), followed by the inclusion of unemployment benefits. Presently, we offer comprehensive coverage encompassing family allowances, unemployment benefits, mandatory health insurance, retirement benefits, short-term benefits, daily sickness allowances, and maternity benefits, for private-sector employees
Approximately three years ago, under the direction of His Majesty, an important decision was made to rectify this situation. We could no longer accept that 60 percent of Moroccans were excluded from social protection. The decision was to extend social protection to all Moroccans within a five-year timeframe.
In 2021 and 2022, we focused on universal mandatory health insurance. In 2023 and throughout 2024, we will extend family allowances. Following that, in 2025, we plan to introduce universal retirement and unemployment benefits, primarily for those with stable employment.
This is a highly ambitious undertaking, and CNSS was tasked with spearheading the initial phase of this expansion. It primarily pertains to operational planning, as we have been entrusted with the responsibility of overseeing the mandatory health insurance scheme for both non-salaried workers and vulnerable populations.
Do you also provide coverage for medical care and hospitalization, or is it solely compensation for work-related incidents?
We cover hospitalizations, outpatient care, and pharmacy expenses. It’s a truly universal coverage.
Was the decision to expand coverage in 2020 simply a consequence of the COVID-19 pandemic or the result of a longer-term plan?
Morocco’s decision to expand social protection and introduce universal healthcare wasn’t solely a response to the COVID-19 pandemic. While the pandemic highlighted the global importance of strong social safety nets, Morocco had been working on these initiatives long before. Led by His Majesty’s vision, the country had already initiated various social programs aimed at addressing social issues. However, the challenge lies in optimizing the impact of these programs by effectively targeting the most vulnerable populations.
COVID-19 accelerated the urgency of social protection, aligning with Morocco’s ongoing efforts to streamline and expand these programs, particularly in terms of ensuring universal access to healthcare services.
Morocco has implemented two key mandatory healthcare plans (AMO) to enhance social protection. One program caters to non-salaried workers (AMO-TNS), including farmers, traders, and artisans. The other, called “AMO Tadamon,” (solidarity) targets vulnerable populations identified through a Unified Social Registry (RSU). The government covers insurance premiums for these individuals, ensuring they receive the same level of healthcare coverage as salaried workers. This initiative aims to provide comprehensive protection to all Moroccans, prioritizing those with the greatest needs. In summary, Morocco’s efforts to expand social protection and establish universal healthcare exemplify a sustained commitment to addressing social disparities and guaranteeing access to vital services, particularly during challenging times.
The Unified Social Registry is a system that allows for the allocation of an objective, verifiable, and entirely rational score. Based on this score, if you are below the threshold, the government covers your contributions.
The government has allocated nine billion dirhams to cover the contributions of these vulnerable individuals. This support extends to approximately four million insured individuals under the AMO-Tadamon, and when we factor in beneficiaries, such as spouses and children, the total reaches around ten million people. This accounts for more than a quarter of the Moroccan population.
Since December 1, 2022, these vulnerable populations have been benefiting from the Mandatory Health Insurance services, which are the same as those provided for salaried workers and non-salaried workers. It was important not to have a two-tiered system with different levels of coverage, ensuring that both salaried individuals and vulnerable populations receive the same quality of coverage. This means that today, someone who is vulnerable is covered and can seek medical care in both the private and public sectors.
How did you address the issue of funding and implementation given that these are complex matters which inherently involve operating at a deficit, posing financing challenges before tackling implementation details?
Regarding the healthcare system for vulnerable populations, we streamlined it due to the limitations of the previous RAMED system, which essentially acted as a medical assistance program. Unfortunately, RAMED was confined to the public sector. Consequently, when a vulnerable individual required medical attention, they were informed of their entitlement to services like scans at regional or provincial public hospitals. However, in practice, they frequently encountered significant wait times, sometimes ranging from three to six months before gaining access to the required healthcare.
Considering this, we implemented a transition plan on December 1, 2022. This involved moving all individuals who were previously enrolled in RAMED into the AMO Tadamon (Solidarity) health insurance system. We allowed a grace period during which these individuals could undergo the Unified Social Registry evaluation to determine their eligibility score. Those who met the criteria and fell below the score threshold became eligible for benefits, whereas those exceeding the threshold were notified that their benefits would be discontinued. This adjustment aimed to establish a more equitable targeting system.
Registration with the Unified Social Registry is an ongoing process, allowing even individuals who were not previously part of RAMED but considered themselves vulnerable to sign up. Currently, the Ministry of the Interior manages this registry. However, there are plans for a government agency to take over this responsibility in the future.
Does the mentioned “score” align with the one employed in the past for the RAMED program?
The new system through the RSU (Unified Social Registry), is substantially different from the previous one known as RAMED. RAMED involved local committees making decisions, whereas RSU employs a questionnaire-based approach with around 26-27 verifiable indicators. This questionnaire assesses various aspects, mainly household expenses, to determine eligibility more accurately. The RSU system has significantly improved targeting. Additionally, the Ministry of the Interior provides databases, enabling real-time exchanges for quick registration and immediate benefits access. Currently, we effectively process an additional 30,000 health claims per day, reflecting its efficient functioning and widespread adoption.
Have you negotiated preferential rates in the non-public sector?
There is a national reference pricing system in place, which is set and regulated by authorities. Consequently, these rates are applied uniformly.
How about the next steps, including for non-salaried workers?
Today, we have already registered just under two million non-salaried workers, including farmers, traders, artisans, and more. The process involves what we call liaison organizations. For the agricultural population, it’s the Ministry of Agriculture that acts as the liaison organization. Similarly, for traders, it’s the Ministry of Commerce, and for artisans, it’s the relevant ministry. We have these liaison organizations categorized by profession.
These organizations provide us with databases of individuals within their respective categories. These databases typically include names, ID numbers, and other available information. Once we receive this data, we go through a rigorous validation process. This process includes ensuring compliance with data protection regulations under the supervision of the National Commission for the Protection of Personal Data.
We then proceed to register these individuals and initiate contact with them. For each professional category, we have a fixed contribution rate based on a flat income. These rates were determined through negotiations with professional associations. This flat-rate approach was chosen because actual income can be challenging to assess accurately.
Did you need to expand your workforce and technological support?
We haven’t significantly increased our workforce at CNSS; despite our activities growing nearly threefold, our staff has increased by perhaps only twenty or thirty percent. The reason for this is that we have relied on two main factors: digitization and strategic partnerships.
For instance, today, most of our services, excluding mandatory health insurance, are fully digitized. If you want to process a pension claim, request family allowances, or apply for unemployment benefits, there’s no need to submit physical documents or visit our offices. Documents, if needed, can be uploaded onto our portals and processed digitally in the back office.
Additionally, for example, there are family allowances that are dependent on school attendance. We have an information exchange with the Ministry of Education, so we largely don’t require people to provide us with school certificates. These partnerships, play a crucial role.
The only service that hasn’t been fully digitized yet is mandatory health insurance due to the continued use of “paper medical claims”. To accommodate the rapid increase in our insured population, we needed to expand our network. Instead of opening new branches, we relied on what is known as “payment points.” These are small entities, some of which are franchises, that primarily handle money transfers but also offer other services.
These payment points are under the supervision of specific governmental bodies, depending on their type. Through an IT-based system, individuals can now submit their medical claims at these establishments. As of 2021, we had around 110 branches in our network, but we’ve since increased it to approximately 170. However, our partners have provided us access to about 2,000 additional points of service. As of the previous week, these points of service were responsible for processing 90 percent of the total claims. These establishments are often located in all neighborhoods, offering incredible coverage and convenience. They’ve established a strong presence in the community, and people are accustomed to visiting them for various services. Importantly, these services are highly secure. Despite this change, we’ve actually improved our claim processing times. Previously, our reimbursement cycle took around ten days; now, it’s down to about nine and a half days.
So, in summary, we haven’t significantly increased our workforce due to the effective utilization of digitization and strategic partnerships, which have been essential in handling our growing workload.
Regarding mandatory health insurance, we’re also working on a project to fully digitize the process. We hope to have the technological platform ready by March or April 2024, with a deployment timeline of 18 to 24 months. Once this is complete, our services will be entirely paperless, and the importance of the community service points may change accordingly.
What solutions has Morocco found to finance its social protection programs and universal health coverage to ensure economic sustainability?
On the financing aspect, a deliberate choice has been made in Morocco to adopt a contributive basis. This means that direct taxation isn’t the primary source of funding; rather, taxation indirectly contributes to the system. The government covers the contributions 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 contributions.
In terms of financing, there are two crucial considerations. First, it’s essential to determine the appropriate contribution level accurately. Second, it’s vital to control the expenses of the programs over time. In this regard, the regime for salaried workers, which has been in place for nearly 18 years, has been meticulously managed. It has consistently generated surpluses, currently totalling over four billion dollars in reserves. This achievement can be attributed to prudent contribution levels and a gradual expansion of healthcare benefits, rather than rushing to offer an extensive package from the outset.
As for the regimes for self-employed individuals and vulnerable populations, they are still relatively new, and it’s premature to draw definitive conclusions. Extensive studies and ongoing evaluations will be conducted to make necessary adjustments as needed.
In essence, the financing of this system in Morocco is primarily based on contributions from individuals and employers, rather than relying on taxes on items like tobacco or petroleum. How sustainable can this be?
The system, as it is currently structured, is more based on the concept of contributions. In Morocco, we are currently spending around six percent of GDP on healthcare, which might be lower compared to similar countries. In reality, a slight increase, say, one or one and a half percent of GDP, in healthcare spending could be beneficial. Insufficient investment in healthcare often leads to indirect costs, such as decreased productivity and chronic illnesses.
The challenge is to prevent healthcare expenses from reaching an unsustainable level. At CNSS, we are working vigorously on two fronts. First, we have significant projects related to data management because data is crucial for prevention, early and appropriate treatment, fraud prevention, and curbing unnecessary expenditures. second, we are focusing on dialogue with the healthcare ecosystem. We have established a Medical Affairs Department within CNSS to facilitate ongoing communication with healthcare providers. Ultimately, our shared goal is to maintain a stable, well-funded healthcare system that provides quality care to all Moroccans. I believe that effective dialogue is the best way to achieve this.
What is the proportion of medication covered by CNSS in the healthcare systems you serve?
Our current standing is approximately in the range of 25 percent to 30 percent, with variations depending on the various regimes in place.
This seems high compared to the 16 percent we find in European nations like Belgium. Is this something you’d like to revisit, monitor, or scrutinize more closely in the future? is there something on your agenda, that prioritizes reducing these expenditures, or is it not currently a priority?
I hold the view that drawing conclusions based on these figures, utilizing them as benchmarks, and comparing them to other countries may not be entirely relevant. This is because these percentages are contingent on the pricing levels within each country’s healthcare system. For instance, hospitalization costs in Belgium, France, or Germany are inherently higher than in Morocco. However, when it comes to medication expenses, the variation is not as pronounced. For example, a day in intensive care in France might cost around 1,000 to 2,000 euros, whereas in Morocco, it amounts to approximately 150 euros, or 1,500 dirhams, covered by the health insurance system. Apart from medication, the disparities might range from five to ten percent, but they are not as substantial. It is imperative to approach these comparisons with caution
On the other hand, we’re heavily investing in data analysis today. We aim to have a 360-degree view of healthcare providers and our insured population. It’s crucial to know precisely what people consume and what healthcare providers prescribe, to identify areas where improvements can be made without compromising the health of Moroccans. We are genuinely committed to effectively targeting unnecessary expenses. So, we’re making substantial investments in these areas.
Is one of your long-term goals to develop a robust healthcare system that not only helps manage healthcare expenses but also provides a more accurate health data profile to support government policies for addressing health issues like Hepatitis C and cancer?
There are two main facets: the purely digital part for services and the data part. So, for digital transformation, we have three components. The first one pertains to the digitalization of services, aiming for improved service quality for our policyholders and partners at a lower cost.
The second aspect involves data usage, primarily for our own needs, including combating fraud and better managing expenses by eliminating unnecessary spending. The third component, also related to data, is our goal to make this data available to the broader healthcare ecosystem, contributing to a more comprehensive understanding of an epidemiological situation for example. This is something we are actively working on, and it is part of our plan. It does not only involve the Ministry of Health but also other government agencies, academic institutions, the general public, and more.
As for your own organization, given the ongoing reform in CNSS and its expanding role, with new agencies being created, what are your plans for the next four years?
First and foremost, we are an institution dedicated to serving the state, and it is our utmost priority. We were tasked with the initial phase of the AMO (Mandatory health plan), and we successfully integrated, registered, and provided services to new populations in record time, essentially tripling our activity within eighteen to twenty months. This was no easy feat, especially considering that we were not serving these new populations, which our information systems were not originally designed for. Consequently, we had to undertake significant work in a very short period.
Nonetheless, there are still challenges ahead. Our ongoing efforts are aimed at maintaining or even improving the quality of service. This entails substantial work on refining our processes, enhancing our information systems, and focusing on debt collection, especially among self-employed individuals. We are also investing heavily in data utilization tools and undertaking projects over the next three to four years to elevate our value contribution to Morocco’s social protection and healthcare systems.
With the generalization of social protection, particularly in the realm of mandatory health insurance, our role has transformed into that of a genuine insurer. An insurer must manage and anticipate risks, making us a vital part of the system’s overall value proposition. Consequently, this transformation is one of the key challenges we face in the coming years.
In conclusion, our primary objective is to provide exceptional value and service quality, both to ensure the well-being of our citizens and to contribute positively to our nation’s social protection and healthcare systems.
Is there anything else you would like to include or discuss, beyond the mandatory health insurance reform, its financing, and its functioning aspects?
As we were discussing various ongoing projects and reform initiatives, it’s worth noting that alongside the mandatory health insurance reform, there is another ongoing reform related to the healthcare sector in general, both in the public and private sectors. This reform encompasses governance changes, including the creation of the High Health Authority and the Medicines Agency, a comprehensive revision of governance structures, and the establishment of regional health territorial groupings.
Furthermore, there are modifications in the conditions for practicing medicine, such as changes in the training curriculum and a broader approach to medical practice. In this context, 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 play a vital role. 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 important. It encourages the public sector to improve its services and efficiency. Overall, this reform has a virtuous aspect that complements the broader healthcare reform.