The general director of the National Health Insurance Agency (ANAM) Dr Khalid LAHLOU outlines the role of the agency as the sole regulatory authority for Morocco’s compulsory health insurance (CHI) within the current context of healthcare reform. He discusses the future challenges facing both new and existing coverage schemes, the need to align all stakeholders, including the pharmaceutical industry, and speaks about Morocco’s role in Pan-African public health cooperation.
What is the role of the National Health Insurance Agency (ANAM) in Morocco’s overall healthcare landscape? How does it collaborate with other healthcare entities?
Our agency has a very important role as the sole regulatory authority for compulsory health insurance (CHI) in Morocco, operating under the provisions of Law 65.00. Our responsibilities encompass various aspects, including ensuring that the objectives of health insurance are in line with the strategic orientations of the national health system, monitoring the financial balance of the funds managing CHI, supervising health insurance operations through the development of standards, regulatory and technical tools aimed at reinforcing access to quality care at the right cost, and guaranteeing the financial stability of the health insurance system.
Within ANAM, our decision-making is guided by a Board of Directors, chaired by the Head of Government, who delegates the chairmanship to the Minister of Health and Social Protection. This Board is the governing body vested with the strategic decision-making power that shapes the health insurance landscape in Morocco. Thus, one of our fundamental functions, is to coordinate and maintain synergies of action between the various stakeholders in the CHI ecosystem, particularly insurers, care and service providers, as well as beneficiaries.
That daily workload is considerable, making our arbitration mission not the least of our responsibilities. In addition, although ANAM does not exercise legislative power, we work closely with the Ministry of Health and Social Protection to contribute to the drafting or updating of essential CHI regulatory policies. At present, in a very special context of social protection reform against the backdrop of a deep overhaul of the national healthcare system, we are focusing on the overall reconsideration of CHI’s regulatory arsenal, in particular to correct the limitations revealed by 17 years of regulation under law 65.00.
Strategically, our missions encompass three fundamental dimensions. Firstly, they serve our national commitment to the international community to achieve universal health coverage —target 3.8 of the health Sustainable Development Goal (SDG° n°3) —for the benefit of all Moroccan citizens, throughout the country.
The second dimension focuses on the funding sustainability of compulsory health insurance. Although our financing system is generally stable, challenges are beginning to emerge, particularly for the National Fund of Social Security Organizations (CNOPS). On the other hand, the National Social Security Fund (CNSS) has a financial surplus that has increased gradually to date, but is beginning to feel the impact of a rapidly changing CHI landscape due to the exponential expansion over the last two years. Our approach to monitoring the financial balance of these two funds involves, in addition to meticulous monitoring of the balance between their income and expenditure indicators, the regular production of projection studies to support them in making the necessary adjustments at the appropriate time. The challenges facing CNOPS in particular require specific attention in the short term. Conversely, the CNSS surplus positions the fund favourably in the short to medium term. However, agile and prudent planning is crucial to ensure the long-term stability and viability of the overall CHI system.
The third dimension of our mission concerns healthcare delivery. In this area, the Directives of His Majesty the King in favour of a profound overhaul of the healthcare system are being implemented in tandem with the reform of social protection in its component of compulsory health insurance generalisation. In this context, we have worked diligently with the Ministry of Health and Social Protection to recast the “CHI regulation” aspects of the new regulatory policies concerning the overall governance of the healthcare system.
At present, the Department of Health is actively preparing the application policies needed to implement the four pillars of the health system overhaul: Governance, Health Human Resources, Digitisation, and Upgrading the healthcare offering. 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 upgrading Morocco’s health and health insurance systems, which are now highly interdependent and complementary.
Going back to the ANAM’s main functions, we are also giving priority to the administrative normalisation of CHI and patient care standardisation within its framework. We also guide the CHI system through essential regulatory measures, including the preparation of a national reference pricing system (TNR), guaranteeing 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.
In addition, we have drawn up a coordinated care pathway project, designed to regulate the care trajectories of insured individuals within the CHI system. Finally, the development of a CHI information system adapted to the requirements of the reform appears to be a critical necessity. This system is essential to strengthening our ability to monitor the financial balance of managing organisations within the context of CHI expansion, to track unjustified expenditure and to anticipate future trends of over-costing and over-consumption. It is the backbone of informed decision-making, and underpins the overall success of the CHI generalisation reform in Morocco.
In conclusion, we are about to integrate the entire Moroccan population into the compulsory health insurance system, with a reassuring financing scheme and commendable efforts towards the comprehensive reform of the national healthcare system in full swing. The future of healthcare regulation in Morocco envisions a healthcare system guided by clear missions and steered by new governance that is driven by the universal principles of accessibility, equity and quality of care, and monitored by a modern, secure and robust information system. Substantial progress has been made, and we are dedicated to ensuring the success of these transformative initiatives.
What changes and developments have taken place at ANAM since your appointment, particularly in terms of supporting health systems and health insurance reforms in Morocco?
Since my appointment, ANAM has undergone significant developments. Initially, we put in place a strategic plan covering the 2020 – 2024 period. However, following the announcement by His Majesty The King of major reforms within the health and health insurance systems, we realigned our strategy to support the generalisation of compulsory health insurance.
This revised strategy has addressed some of the shortcomings of the previous plan, and adapted measures accordingly. It focuses on five key pillars, the first of which involves supporting regulatory reforms. Within this framework, we played an active part in the amendment of Law 65-00 and the promulgation of Law 09-21 on social protection, as well as other related regulatory changes.
The second pillar focuses on expanding the insured population. To this end, we transferred the Medical Assistance Scheme (RAMED), dedicated to the poor, from ANAM to CNSS, and took part in negotiations with representatives of the self-employed to set their contribution rates. Under this pillar, our participation in decision-making studies played a decisive role in the reform of the CHI system.
The third pillar focuses on adapting CHI’s regulation tools. In 2020, we proposed new national agreements, with a new national reference pricing model, although we are still waiting for the CNOPS to agree to this pricing agreement. The fourth pillar emphasized the need to adopt innovative financing instruments. To justify this need, ANAM drew on various economic studies analysing the costs and impact on various health insurance schemes, actuarial projections and the future financial balance of existing schemes, in particular those managed by CNOPS and CNSS, up to 2030 and, over ten years, between 2023 and 2033.
Finally, as a fifth pillar, the information system is a crucial aspect of our control and regulation activities. We have finalised our master plan and developed a portfolio of 40 projects aligned with reform objectives. This includes the upgrading and digitisation of all the standards and references maintained by ANAM, including the national identifier for healthcare professionals and establishments (INPE); the reimbursable drugs guide (GMR); therapeutic protocols (PT); the national reference pricing (TNR); third-party payment; standardised administrative documents, etc., as well as shared medical files, the platforms required for coordinated care paths and a customised information system for the new health insurance reform.
Throughout the planning and implementation of these projects, ANAM has played, and will continue to play, a central role in supporting the reform processes, providing timely and valuable information to guide the decision-making process, especially through our active participation in the Inter-ministerial Commission for the Implementation of Social Protection Reform, which we have supported with evidence-based, factual and accurate data.
What are the main challenges facing Morocco in the years ahead?
In the medium and long term, Morocco will face a number of major challenges for all its social sectors, including its compulsory health insurance system. Firstly, the question of the sustainability of CHI schemes is crucial. This challenge is not limited to new coverage schemes, but will also affect existing schemes. Take for example the CNOPS which covers around 8 percent of the population, mainly public-sector employees. This scheme is characterised by a strong culture of healthcare consumption, the pronounced ageing of its population, a worrying demographic ratio with only 1.6 employees for each pensioner, and rising healthcare costs due to factors such as technological advances and the availability of costly innovative drugs. These factors pose a major risk to the viability of the scheme, and call for innovative financing, regulation and cost-containment measures to redress the situation.
Another challenge lies in matching the requirements of CHI generalisation, guided by the goal of achieving universal health coverage, with the necessary integration of new stakeholders into the healthcare and health insurance ecosystem. Although substantial progress has been made, questions remain about the roles and contributions of various actors, such as the private sector, the pharmaceutical industry, development agencies and local authorities… It is essential to identify these new stakeholders and align their actions within the framework of reform. This requires collaboration, goal-setting and controlled, targeted investment.
To meet these challenges effectively, Morocco is taking the necessary steps to establish a High Health Authority, as provided for by law. This authority will play a central role in enhancing the health insurance regulator’s capabilities, focusing on areas such as quality assurance, continuing education, accreditation and public health priorities. It will also provide a platform for answering questions about new stakeholders and their roles within the healthcare and health insurance reform ecosystem. In essence, the High Authority of Health will be a valuable resource for strategic health planning, public health and the regulation of compulsory health insurance in Morocco, contributing to the sustainable development and success of the sector in the years to come.
How do you see Pan-African cooperation in public health?
Morocco’s commitment to African cooperation in the field of public health is unconditional. His Majesty the King has never ceased to encourage South-South cooperation, which promotes Morocco’s privileged relations with brotherly and friendly African countries, encouraging the sharing of experience and learning from Morocco’s successful practices. As an institutional actor, ANAM actively collaborates with its African institutional counterparts, regulating health insurance, hosting their delegations and exploring partnership opportunities. For example, we recently welcomed a Nigerian delegation, and have concluded potential bilateral cooperation agreements with countries such as Mauritania, Mali, Guinea, Senegal and many others. The year 2023 was particularly noteworthy in this respect, with ANAM welcoming several African delegations, further consolidating existing partnerships and initiating new ones in the field of compulsory health insurance.
The Ministry of Health also plays a key role in sharing Morocco’s experience across the continent. It allocates substantial resources to South-South cooperation initiatives to facilitate this exchange. Nevertheless, we believe that Pan-African cooperation would benefit from going beyond forums and recommendations. While such forums are valuable, they are often insufficient in terms of long-term impact.
Instead, we advocate for the creation of robust partnership mechanisms with shared responsibilities and commitments, and action plans focused on common objectives, ensuring that the agreements reached produce palpable results. To this end, we draw on ANAM’s experience of internal accountability, in particular our system of performance contracts with defined actions and responsibilities, which enables us to monitor progress effectively. When we discuss Morocco’s healthcare system evolution pathway with our African partners, it is a valuable case study for those countries. We are and we remain ready to share our expertise, and offer support and mentoring. The key is to transform cooperative initiatives into achievable, results-oriented efforts that benefit the African community as a whole. ANAM has applied this approach in our renewed 2020-2024 strategy, and we are committed to adapting and achieving our pre-established goals, even in the context of ongoing reforms.
Do you have any final thoughts you would like to share with our international audience?
There is much left to say and share, but I can conclude by highlighting that while we are making great strides towards achieving the various objectives of the Moroccan social protection reform and the overhaul of the healthcare system, we are also gradually moving towards a new strategic governance model, which will undoubtedly have a positive impact on health investment in Morocco.
This reform, with its approved legislation and forthcoming implementation regulations, will establish a new governance structure with strategic positioning, strong leadership and, above all, regulatory bodies empowered to effectively supervise the health insurance system as the principal healthcare and health services payer. ANAM has been preparing for this transition since the announcement of the creation of the High Health Authority, by laying the groundwork for a gradual and secure evolution, building on its achievements and established tools, such as protocols, standards, shared medical records, and information systems.
The key now is to strengthen the legal arsenal and regulatory potential to successfully implement these changes, with a strategic focus on the most important challenge, which is to harmonize CHI schemes and consolidate all health insurance under a single umbrella. This transition, which will see CNOPS migrate to CNSS, will facilitate unified management and agile decision-making to meet the evolving needs of the reform. With the creation of the High Health Authority and shared governance, Morocco is ready to overcome the complexities of health insurance governance and ensure the success of this transformative undertaking, all serving the well-being and health of all Moroccan citizens.