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The Open Public Health Journal

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RESEARCH ARTICLE

Universal Health Coverage in Morocco: The Way to Reduce Inequalities: A

Cross-sectional Study
Kawtar Zahidi1, Abdellatif Moustatraf2, Ahmed Zahidi1,*, Saida Naji3 and Majdouline Obtel1
1
Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Rabat, Morocco
2
National Health Insurance Agency, Rabat, Morocco
3
Faculty of Legal Economic and Social Sciences Souissi, Mohammed V University in Rabat, Rabat, Morocco

Abstract:
Background:
Morocco launched an appeal in 2002 to develop a fundamental law on Basic Medical Coverage. Two systems have been put in place: Compulsory
Health Insurance (AMO) based on solidarity and social security contributions; and a Medical Assistance Scheme based on the principle of social
protection. The objective of these systems is to achieve Universal Health Coverage (UHC) to attain equity and equality in access to health care.
In the international trend, access to economic and social rights has become a significant concern in public policies. This concept, based on the
value of “equity” is now essential in evaluating equal opportunities in social and health systems. More importantly, there is a need to clarify the
difference between the terms equality and equity in health. In most cases, reference is made to the definition used in Anglo-Saxon literature
(equity, equality, fairness). Therefore, not all inequalities are inequities. The difference between equality and equity lies in that the first term gives
the result of comparison without value judgment, while the second makes a judgment that qualifies the result as fair or unfair.
Our study aims to analyze the specific problems related to the healthcare policy focused on allocating the supply of care, and efforts to improve
financial accessibility specifically by developing medical coverage. We will present results that reflect the availability and quality of care in
Morocco and shed light on the problem of not seeking healthcare for financial, geographical, and other reasons. In addition, we will discuss the
difficulties related to the use of care by Moroccan citizens.
The findings of this paper can potentially inform national healthcare policy and add to the small but growing literature on this subject in Morocco.

Methodology:
The methodology is based on research & data taken from official institutional publications from Morocco & United Nations organizations (gray
literature) and data derived from articles published in scientific journals.

Results:
Morocco continues to suffer from disparities in the distribution of health practitioners due to an imbalanced distribution of health infrastructure and
human resources between rural and urban areas. The Health Map developed by the Ministry of Health and Social Protection in 2016 is a very good
tool to monitor the distribution of public health needs in each region, plan the delivery of care, regulate spending, and consolidate regionalization
policy to ensure equity in supply and access to health care. At the end of 2021, the national average ratios were 7.3 physicians and 10 beds per
10000 inhabitants. In 2018, more than 60% of the Moroccan population enjoyed basic medical coverage and the Moroccan Government is
committed to reaching 100% of Universal Health Coverage (UHC) by 2030.

Conclusion:
The health map will make it possible to control health expenditure by allocating human and financial resources according to needs and will
determine the future location of health facilities to establish equity in the offer and access to health care.

Keywords: Accessibility, Health equity, Health expenditures, Health cost universal health coverage, Financial resources, Health care.

Article History Received: August 30, 2022 Revised: December 16, 2022 Accepted: December 20, 2022

1. INTRODUCTION entry of individuals and population groups into the health care
Access to health care refers to the processes related to the delivery system [1]. It is a multi-faceted concept involving five

DOI: 10.2174/18749445-v15-e221222-2022-160, 2022, 15, e187494452212220

2 The Open Public Health Journal, 2022, Volume 15 Zahidi et al.

dimensions: affordability (costs of using health care), 2. METHODOLOGY

acceptability (compliance with and satisfaction with health
services), availability (adequacy of the provision of health), 2.1. Study Design
geographical accessibility (spatial distribution of health
In this paper, we are particularly interested in non-genetic
structures and services), and accommodation (relevance and
and non-biological inequalities, which are considered
adequacy of health services). These five dimensions show us
that access to health care can be measured and integrated into avoidable and unfair. As an immediate corollary to this, we can
the design and monitoring of a country's government policy take the example of biological inequalities between men and
[1]. women or between young and old, which are not considered
inequities. On the other hand, the fact that a child born in a
The medical coverage of the Moroccan population has developed country like Japan can expect to live to 85 years or
increased considerably in less than 15 years, but there is still a more while in an African country like Sierra Leone, the life
long way to go to achieve Universal Health Coverage (UHC) expectancy is less than 55 years constitutes a flagrant inequity
[2]. [5].
According to the main findings of the evaluation of the
Medical Assistance Scheme (RAMED) carried out by the 2.2. Data Sources
National Observatory for Human Development (ONDH) in Our study aims to analyze the specific issues related to the
2017: 1) RAMED is a relevant instrument for the reduction of Moroccan health policy centered on the allocation of the
social inequalities in access to care. (2) The generalization of healthcare offer, and the efforts to improve financial
RAMED has indirectly put the public hospital service under accessibility, specifically by developing medical coverage.
great strain. (3) The financing of RAMED is still problematic,
As such, to analyze Morocco's specific situation, our
and (4) The targeting of RAMED, unfortunately, does not
methodology is based on research and data taken from official
cover the poorest [3].
institutional publications in Morocco. The main source is the
To assess inequity, we must look at health both from the Ministry of Health and Social Protection (MSPS), which is
perspective of demand and the supply of care. In other words, responsible for developing and implementing government
it is necessary to explore not only the difficulties of policy pertaining to national health. They are also behind the
internalization by individuals of the requirements of good creation and implementation of The Moroccan Health Map.
health but also the degree of coverage of the population by the The second source is the National Agency for Health Insurance
existing healthcare offer. (ANAM) which is responsible for providing technical support
The Moroccan Ministry of Health and Social Protection for Compulsory Health Insurance (AMO) and ensuring the
(MSPS: Ministère de la Santé et de la Protection Sociale) has implementation of system regulation tools.
adopted a multitude of strategies and interventions, which These national data sources and academic research on the
consist of acting on the Social Determinants of Health (DSS) to subject provide a well-rounded view of the healthcare offered
improve the health of the Moroccan population in general, in Morocco. The specific data for this cross-sectional study
while reducing regional disparities and health inequities were obtained from the analysis of documents such as:
(extension of medical coverage, reduction of maternal
mortality and infant mortality with a focus on rural areas, etc.). Moroccan administrative law specific to healthcare.
However, continued and optimal efforts are needed to: (1) Publications of certain public institutions: the Ministry
further improve indicators (such as national averages) of health of Health and Social Protection & the Agency National
to catch up with other countries and (2) reduce inequities Insurance & Sickness.
related to socio-demographic factors to improve the health of The content of the websites of the above public
the entire Moroccan population and to ensure the well-being of institutions.
all, without leaving anyone behind. The Moroccan Health Map
Relevant research on health inequities.
In a quantitative survey on access to care carried out
An institutional analysis of the departments likely to
between 2010 and 2011, 1200 questionnaires were distributed
act on a given Determinants Social Health (DSS).
in three contrasting geographical zones: an urban area, a
A review of the existing coordination mechanisms
mountainous area, and an arid zone sparsely populated and far
which are supposed to promote joint or at least
from decision centers. The results of this survey showed that
concerted actions between the different actors
more than 80% of the surveyed population said that access to
mobilized for human development.
care facilities is perceived as difficult to very difficult and that
the quality of care is poor or inadequate. This proportion rises
to more than 90% in the arid zone. The financial barrier is the 2.3. Data Management and Analysis
main reason for 67.2% of the population waives private The data was analyzed with Microsoft Office Excel 2019
medical consultations. This proportion rises to 81.3% in the and summary statistics were used to estimate the ratio of
arid zone [4]. inhabitants per hospital bed and inhabitant per doctor. This is a
secondary study that used data extracted from existing Ministry
* Address correspondence to this author at the Faculty of Medicine and
Pharmacy, Mohammed V University in Rabat, Rabat, Morocco; of Health and Social Protection data. Thus, no ethical approval
Tel: +212667323273; E-mail: [email protected] and no consent to participate were necessary.
Universal Health Coverage In Morocco The Open Public Health Journal, 2022, Volume 15 3

3. RESULTS This density is very far from the critical threshold

recommended by the WHO for the achievement of the SDGs,
3.1. The National Health System namely 17.5 doctors and 39.0 nurses per 10,000 inhabitants [6].
Health equity in Morocco is well underlined by the Dahir An inequitable distribution between the regions of Morocco
n° 1-11-83 of July 2nd, 2011 promulgating the framework law exacerbates the deficit in medical personnel. This same data
n°34-09 relating to the health system and the supply of care analyzed according to the ratio of inhabitants per physician
(published in the Official Bulletin n°5962-19 of July 21, 2011). (public and private), reveals that the regions of Rabat-Salé-
Indeed, Article 2 of this framework law indicates that “The Kenitra, Fes-Meknes, and Casablanca-Settat have a coverage
health system is made up of all the institutions, resources and higher than the national average, which is one physician for
actions organized to achieve the fundamental health objectives 1,356 inhabitants. In fact, the region of Casablanca-Settat holds
based on the following principles: - The equal access to health the first rank with a physician for 897 inhabitants, followed in
care and services; - The solidarity & responsibility of the the second position by the region of Rabat-Salé-Kenitra with a
population, in the prevention, conservation and restoration of physician for 1,075 inhabitants. On the other hand, the region
health; - Equity in the geographical distribution of health of Beni Mellal-Khénifra and that of Drâa-Tafilalet have the
resources; - Intersectoral complementarity; - The adoption of lowest ratio, with a physician for 2,511 inhabitants and a
the gender approach in health services. The implementation of physician for 3,396 inhabitants, respectively.
these principles is primarily the responsibility of the State”. Regarding the distribution of public physicians in the
The National Health System is made up of: different regions, there is a high concentration of physicians in
the regions of Casablanca-Settat, Marrakesh-Safi, and Fez-
A public sector comprising the structures of the Meknes. These three regions count 7,857 public physicians,
Ministry of Health and Social Protection and the health representing 57.4% of all physicians.
service of the Royal Armed Forces, As presented in Fig. (2), the data taken from the Health
A private non-profit sector comprising the Map show us that in Morocco, the supply of health care is
establishments of the National Social Security Fund weak at the level of health facilities, that the human resources
(CNSS) and mutualist establishments, are not sufficient and that there is a great disparity between the
A private for-profit sector made up of clinics, medical twelve regions of the country.
consultation offices, radiological examination offices,
medical analysis laboratories, dental surgery offices, 3.3. Reasons for not Seeking Health Care
nursing care offices, midwives, and pharmacies.
The decision to use a healthcare worker is made in most
In practice, the health policy of the Moroccan government cases when symptoms persist, especially for patients away
is implemented by the Ministry of Health and Social from health centers. The decision to use a physician is made
Protection, mainly through two networks: the network of collectively; generational hierarchy, gender relations, and
primary health care establishments and the hospital network. economic dependency relationships are key factors [4].
The constraints to accessing the health center are often
3.2. Coverage Indicators important. They range from transportation costs, difficulties in
The figures given by the 2021 health map indicate that the finding a vehicle in isolated areas (sometimes including urban
public infrastructure includes 861 urban health centers, 2,124 areas), expenses related to housing and meals with
rural health centers, 165 hospitals with 23,786 functional beds, accompanying persons, and specific expenses associated with
10 psychiatric hospitals with 1,374 functional beds, and 128 medical care (laboratory tests, medications, etc.) [4].
hemodialysis centers equipped with 2,613 dialysis machines. Once the decision has been made and the route is taken,
As for the private infrastructure, it includes 384 clinics with patients often face new barriers at the reception of the
12,534 beds and 234 hemodialysis centers. The national healthcare facility that may increase the length of care. For
average ratio is 936 inhabitants per hospital bed. This ratio instance, baksheesh and/or intervention of interconnections
varies from 693 to 2330, which is a multiple of 2.48x the constitute the factors favoring access to the provider. The
national average at its maximum. Of the 12 regions of objective displayed by the patients is to reach the physician,
Morocco, 8 regions have a ratio higher than the national and preferably, the medical specialist; the unavailability or
average. Fig. (1) shows that this ratio can be expressed as an absence of the physician is quickly perceived as a failure in the
average of 10 beds per 10000 inhabitants. face of all the efforts made to access care [4].
Regarding human resources, especially physicians, The interactions with the physician will be all the more
Morocco has 27,881 physicians (public & private combined) in facilitated and appreciated if he speaks the patient's language,
2021, of which 50.9% are in the private sector and 65.2% are
understands his daily practices, and knows his living conditions
medical specialists.
and the pathologies of his context; the physician who hails
The shortage of health personnel is a major problem for the from the region where he practices is then presented as the
Moroccan health system. The health map set the density per ideal practitioner. The specialist physician practicing in large
10,000 inhabitants to 7.3 for physicians (public and private). cities) and his own region is also particularly sought after [4].
4 The Open Public Health Journal, 2022, Volume 15 Zahidi et al.

Fig. (1). Inhabitant ratio per hospital bed according to 12 regions of Morocco. (Source of data drawn and adapted from the health map, Ministry of
Health and Social Protection. July 2022 [17].)

Fig. (2). Inhabitant ratio by public and private physicians according to 12 regions of Morocco (Source of data drawn and adapted from the health
map, Ministry of Health and Social Protection. July 2022 [17].)

3.4. Sources of Health Care Expenditures in Morocco household expenditure relative to the Total Health Expenditure
(THE) indicates the level of financial protection a country
Health financing in Morocco is characterized by a provides to its people. One of the objectives of Universal
multiplicity of funding actors. These consist of public sources Health Coverage (UHC) is to reduce this ratio to less than 25%.
through state tax revenues, health insurance contributions The goal is to ensure that collective health financing is based
(including various forms of private insurance), and private on national solidarity and ensure a maximized pooling of
sources through direct household payments. The ratio of direct health risks.
Universal Health Coverage In Morocco The Open Public Health Journal, 2022, Volume 15 5

Table 1. Sources of financing health care by nature in Morocco, 2018*.

Funding Sources 103 USD** Percentage

Households 861 731.5 14.1%
Public Enterprises and institutions 40 825.6 0.7%
State 203 341.8 3.3%
Contribution to the AMO
Private enterprises 665 642.3 10.9%
Territorial Communities 25 364.7 0.4%
Subtotal 1 796 905.9 29.5%
Households 2 777 133.4 45.6%
State (Budget) 1 356 007.2 22.3%
Territorial Communities 95 423.0 1.6%
Direct contributions to health services (excluding AMO) Employers 23 692.6 0.4%
International Cooperation 13 155.9 0.2%
Other (ONGs,…) 30 434.7 0.5%
Subtotal 4 295 846.8 70.5%
Total 6 092 752.7 100%
Note: *Data from “Comptes Nationaux de la Santé” (National Health Accounts), 2018 [7].
**Estimated costs after conversion of the Moroccan Dirham (MAD) into USD with an exchange rate of 1 USD =10 MAD.
AMO: Assurance Maladie Obligatoire (Compulsory Health Insurance)
Since 1997, we note that several efforts have been made to improve health financing in Morocco.

In 2018, the direct household expenditure constituted as direct payment (OOP: Out of Pocket) and 8.6 billion in the
45.6% of THE versus 50.7% in 2013. Thus, the drop of around form of contributions to health insurance.
5% constitutes a positive element for the health financing
system in Morocco [7, 8]. In addition, the country's From 2013 to 2018, the share of the country's health
contribution to health financing remains almost unchanged at financing stagnated at around 25%, while that of households
24% in comparison to that of 2013. The share of health fell from 63.1% to 59.7%. The share of Private Enterprises. is
insurance in the financing of health expenditure is 29.3%, 1.1%, thus registering a decrease of 3% compared to that of
which is an increase of 6.9 points compared to that of 2013. 2013. This reduction is explained by the evolution of the share
The respective contribution shares of public enterprises and of health insurance, which has evolved to reach 29.3% of the
institutions and international cooperation are 0.4% and 0.2%
DTS in 2018 [7, 8].
[7, 8].
It should be noted that collective and solidarity/mutual In value, direct household expenditure increased from 1.75
financing reached 53.3% in 2018 versus 46.8% in 2013. The billion dollars in 2006 to 2.78 billion dollars in 2018. Relative
improvement of solidarity financing constitutes a positive trend to the population size, direct household expenditure per capita
toward financial protection of the population and especially the fell slightly between 2010 and 2018 (USD80.2 per inhabitant in
most vulnerable segments. 2010 versus 78.9 USD per inhabitant in 2018), while it was
The evolution of health financing should in principle, tend USD57.4 per inhabitant in 2006. In addition, we note that the
towards an increase in the share of health insurance for more financial protection provided by medical coverage (AMO,
solidarity and risk pooling. In 2018, Morocco spent 60.9 billion RAMED, internal and mutual funds, and private insurance
dirhams on health, an increase of 8.9 billion MAD since 2013. companies) substantially reduces direct payments by
Taking into account an exchange rate of 1 USD for 10 households. Since 2006, the share of direct payments by
Moroccan Dirhams (MAD), this represents a little more than
households has continued to fall, falling from 57.3% in 2006 to
6.76 billion USD; which represents 5.5% of GDP compared to
53.6% in 2010 and 50.7% in 2013 [7, 8].
5.8% in 2013. The average annual expenditure per inhabitant is
186.3 USD [7, 8]. The implementation of the code of the CMB has made it
Household participation in health expenditure is estimated possible to increase the level of funding of the health system in
at 2.78 billion Dollars in the form of direct expenditure in significant proportions and to promote its collective and
2018, which represents 45.6% of THE. When we add to the solidarity financing. Moreover, it is not only a question of the
direct contribution of households the contributions to health solvency of demand and reconsidering the field of solidarity
insurance, which they make on an annual basis, this percentage but also of strengthening the effectiveness of the entire national
rises to 59.7% of the THE [7, 8]. health system and in particular its public component. Indeed,
The breakdown of funding sources for health costs is given the establishment of the AMO and the RAMED made it
in Table 1. possible to improve the financial situation of the establishments
Analysis of the sources of financing shows that households of health care, in particular the public hospitals, which
remain the main financiers of health, with 27.8 billion dirhams represent 80% of the bed capacity of the country.
6 The Open Public Health Journal, 2022, Volume 15 Zahidi et al.

4. DISCUSSION and (iii) the basis of the global analysis of existing healthcare
provision, geo-demographic and epidemiological data, and
4.1. Supply, Availability, and Quality of Care medical technological progress [14].
Regarding access to care, the analysis shows that none of The supply of care is defined, therefore, according to a
the indicators point to a clear priority for action. However, process that aims at ensuring the full employment of human
more equitable access to health care could be obtained mainly resources and health infrastructures to satisfy the needs of the
by reducing regional disparity. The lack of financial means as a population. At this level, the care system integrates several
reason for not seeking care, as an indicator, seems to show a actors, each of which participates through its unique and
moderate degree of inequity. The well-being score, urban indispensable role.
environment, and high school level or higher are the
socioeconomic factors that contribute the most to the inequities The itineraries, the difficulties experienced and the
exhibited by the indicators related to access to care. perceptions of quality of care make it possible to identify the
multiple constraints that influence the decisions of the
Under the principle of availability, the provision of care population to resort to a healthcare provider.
must be distributed throughout the national territory in a
balanced and equitable manner. Public and private sector The Health Map developed by the Ministry of Health and
institutions, whether for-profit or not, need to be synergistically Social Protection was used as the main tool to examine the
organized to respond effectively to health needs through distribution and availability of healthcare, information on
complementary, integrated, and coordinated healthcare financing, and the use of budgetary and human resources [17].
services.
4.2. Basic Medical Coverage in Morocco
In Morocco, there is a great lack of availability of care
services that lies in the configuration of its offer. In addition, The development of Basic Medical Coverage (CMB) was a
the malfunctioning of healthcare facilities makes it difficult to key step in realizing the principle of the right to health for all
implement equitable funding. They also complicate the and the involvement of various stakeholders in the
development and application of medical supervision to ensure improvement of the healthcare system. The CMB was
the quality of care [9, 10]. established by Law N° 65-00 published in 2002 and entered
into force on August 18, 2005, by decree of application [9, 10,
Inequity in the allocation of financial resources manifests 18].
itself at several levels and mainly affects the use of care
services. Law N° 65-00 on Basic Health Insurance Code introduced
Compulsory Health Insurance (AMO) and the Medical
The supply of care contributes to producing a growing Assistance Scheme (Régime d’Assistance Médicale; RAMED).
demand for health. From this demand emerged a system with The AMO is based on the principles and techniques of social
actors with rights and responsibilities. In fact, medicine, insurance for the benefit of persons in remunerative
medical procedures, and other care services have a social cost employment, pensioners, former resistance fighters and
and a price that are both defined in a healthcare market funded members of the Liberation Army, and students. In addition,
by several stakeholders [11, 12]. RAMED is based on the principles of social assistance and
From an economic perspective, it will be the role of the national solidarity for the benefit of the poor. This code is the
state to control the cost of public health so that it is covered by foundation of social protection in health [18].
public health expenditures while applying the principles of the The purpose of setting up RAMED is to provide poor
right to health [13]. populations not covered by Compulsory Health Insurance with
The organization of the care supply obeys several rules access to quality health services. RAMED seeks to address the
throughout its process of integration into the health care need for equity and social justice in access to health care while
system. In Morocco, to respect the principles of Article 2 of reducing the stigma and barriers associated with the former
Framework Law N° 34-09 [14], the provision of care must be system of exemption from payment based on the neediness
spread throughout the national territory in a balanced and (“poverty”) certificate issued by the local administrative
equitable manner. However, this is a challenge because even authorities.
with the significant growth in supply and distribution, it
RAMED medical coverage contributes to the explanation
remains unbalanced in terms of infrastructure [15, 16].
of the inequities induced by the access to places of
The four main objectives of the provision of care are (i) To consultation. But it should be noted in this case that people
anticipate and bring about the necessary evolutions of the with general medical coverage consult more than those without
supply of care (public and private); (ii) optimally satisfy the it.
health care and services needs of the population; (iii)
Achieving harmony and equity in the spatial distribution of 4.3. Covered Populations and Access to Care
material and human resources; and (iv) Correcting regional and
Above all, it is necessary to recall that social inequalities,
intra-regional imbalances and managing supply growth.
health inequity, and territorial disparities in Morocco constitute
The supply of care is established according to three a persistent phenomenon recognized at the highest level of the
criteria: (i) the types of infrastructure and sanitary facilities; (ii) State. Indeed, several Royal speeches have drawn attention to
the norms and the modalities of their territorial implantation; this bane which hinders the development of the country, in
Universal Health Coverage In Morocco The Open Public Health Journal, 2022, Volume 15 7

particular the Royal speech of August 20, 2019, in which the two essential principles, namely equity and equality in access
King of Morocco set up the special commission on the to care.
development model (CSMD), which published its general
The portion of a patient's direct payments has a serious
report in May 2021 and in which it is pointed out, among other
health impact because people who cannot pay for care are
things, that in terms of citizen impact, “All citizens, regardless
discouraged from seeking care. As a result, they do not receive
of their socio-professional status and their place of residence,
early treatment despite a much higher healing potential.
are equal in front of health, with access to protective health
Therefore, the Moroccan government is seeking to promote
coverage and a quality care offer” [19].
health insurance through AMO and RAMED due to its ability
To achieve coverage for 90% of the population, in 2017 to reduce the burden of household spending on health.
the legal and regulatory framework for medical coverage of
The move towards universal health coverage faces
professionals, self-employed workers, and self-employed
challenges such as:
persons was promulgated.
1. Extending coverage to populations not covered,
In 2005, the rate of medical coverage of the population of
including the liberal sector and the self-employed.
Morocco; all medical coverage plans combined, was 16%.
2. The reduction of direct household expenditure (OOP:
In 2019, this rate reached 70% (AMO: 30%, RAMED:
Out of Pocket) and the financial protection of the population
30%, special schemes: 5%, categories benefiting from article
against catastrophic expenditure
14 of law 65-00: 4% and students: 1%) [2].
3. The request for increased funding and its sustainability
In April 2021, his Majesty King Mohammed VI kicked off
the project to extend social protection to all Moroccans with 4. The equitable availability of essential services and the
the generalization of Mandatory Health Insurance (AMO) quality of these services
before the end of 2022. However, continued, and optimal efforts are needed to: (1)
According to the national barometer on access to care and further improve indicators (such as national averages) of health
medical follow-up of the insured persons of the National Fund to catch up with other countries and (2) reduce inequities
of Social Welfare Organizations (CNOPS) and the National related to socio-demographic factors to improve the health of
Social Security Fund (CNSS), carried out between the end of the entire Moroccan population and to ensure the well-being of
2010 and the beginning of 2011, the use of AMO beneficiaries' all, without leaving anyone behind.
care has been characterized by situations of dissatisfaction
which must be corrected [20]. First, the complexity of the STRENGTHS AND LIMITATIONS
administrative procedures for opening rights to health This paper relies heavily on the Health Map developed by
insurance or agreements for organizations managing the the Ministry of Health and Social Protection in 2016. It is a
treatment in third-party payment mode, in addition to the list of quite powerful reporting tool that makes the data used in this
reimbursable medicines which is considered limited by the paper very reliable as they are officially sanctioned data, and it
insured. Adding to that, the delay of reimbursement of sickness is made available to the wider public. This is however also the
records was judged by 52% of dissatisfied insureds as too long limitation of this paper. If there are any internal data
[20]. In other words, the intervention process regarding the discrepancies, however unlikely, within the Ministry’s dataset;
rights of the insured and meeting the needs expressed by the then it would impact the reliability of our findings. To account
beneficiaries of the AMO remains long and provokes conflicts. for this possibility, future studies can focus on a randomized
On the other hand, more than half of the insured through verification study to validate the data.
AMO state that accesses to care in general is satisfactory, with
good coverage of expensive care (Chronic Disease, LIST OF ABBREVIATIONS
Hospitalization, and Surgery), and with a quality reception at For some = We have adopted in the manuscript the
the counter and information of the rights and benefits is abbreviations French abbreviations commonly used in
provided [20]. Morocco.

For poor people, the management framework suffers from AMO = Health Insurance Compulsory (Assurance
Maladie Obligatoire)
bureaucracy, non-standardization, and the subjectivity of
RAMED's eligibility criteria. Although the price of ANAM = Agency National Insurance & Sickness
consultations in public facilities is the lowest on the market, it (Agence Nationale de l'Assurance Maladie)
did not significantly improve RAMEDists' access to care [9, CMB = Basic Medical Coverage (Couverture
10]. Médicale de Base)
CNOPS = National Fund of Social Welfare
CONCLUSION organizations (Caisse Nationale Des
Organismes De Prévoyance Sociale)
Since the organization of the first national health
CNSS = National Social Security Fund (Caisse
conference in 1959, Morocco has had a National Health
Nationale de Sécurité Sociale)
System (SNS) capable of responding to international
challenges. DSS = Determinants Social Health (Déterminant
Social de santé)
It should be remembered that the use of care is based on
8 The Open Public Health Journal, 2022, Volume 15 Zahidi et al.

implementation of the third phase of the INDH, from 2019 to 2023.

GDP = Gross Domestic Product
2019. Available from:
MAD = Moroccan Dirham (code of the official http://www.indh.ma/wp-content/uploads/2019/09/Livret_INDH_VF.p
monetary currency of Morocco) df
[3] One. Evaluation du RAMED, Report Annul Day L'Ond 2017. 2017.
MSPS = Ministry of Health and Social Protection Available from:
(Ministère de la Santé et de la Protection https://www.ondh.ma/fr/publications/rapport-de-levaluation-du-regime
Sociale) -dassistance-medicale-ramed
[4] Gruénais ME, Amine M, De Brouwere V. Qualitative survey on access
ONDH = National Development Observatory Human
to care among the population. In: Disparities in access to healthcare in
(Observatoire National du Développement Morocco. Rabat: National Observatory of Human Development 2011;
Humain) p. 246.
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