69710 KINGDOM OF MOROCCO HEALTH POLICY NOTE TOWARDS A MORE EQUITABLE AND SUSTAINABLE HEALTH CARE SYSTEM - POLICY CHALLENGES AND OPPORTUNITIES POLICY NOTE (P104274) MIDDLE EAST AND NORTH AFRICA SOCIAL AND HUMAN DEVELOPMENT GROUP (MNSHD) Document of the World Bank Vice President Daniela Gressani Country Director Theodore Ahlers Chief Economist Mustapha Nabli Sector Director Michal Rutkowski Sector Manager Akiko Maeda Task Team Leader Enis Barış This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank ii TABLE OF CONTENTS Acronyms and Abbreviations v Acknowledgements vi Executive Summary 1 Introduction: Scope and Purpose of the Policy Note 5 Chapter 1: Health and Health Care in Morocco - An Overview 6 1.1 Health and Demography 6 1.2 Poverty and Inequalities in Health and Health Care; Patterns and Trends 9 1.3 Patterns and Trends in Supply of Health Care 15 Chapter 2: Main Sectoral Issues 17 2.1 Stewardship and Governance 17 2.2 Health Financing and Expenditures 20 2.3 Resource Allocation and Purchasing 25 Chapter 3: An Agenda for Health Sector Reform 29 3.1 Reducing Inequalities in Health and Access to Care 29 3.2 Improving Allocational and Technical Efficiency 32 3.3 Reforming System Governance and Regulatory Framework 34 Chapter 4: A Way Forward 36 A Policy Matrix for Improved Health Sector Performance 40 References 45 ANNEXES Annex 1: Progress with Achievement of MDGs in MENA 47 Annex 2: Health System Attainment and Performance in MENA, Spain and Turkey 48 Annex 3: Demographic Profile in Morocco 49 Annex 4: Inequalities in Health, Morocco, 2003-2004 50 Annex 5: Levels and Composition of Health Expenditures in World Bank Regions and Income Categories, 2004 51 Annex 6: Resource Allocation for Improved Efficiency 52 Annex 7: Hospital Payment Mechanisms; Incentives and Risks 53 Annex 8: Governance and Human Development in Morocco, 2005 54 BOXES Box 1. Poverty, Gender, Education and Health 10 Box 2: Inequalities in Access to Primary Health Care in Morocco, 2004 15 Box 3: Informal Payments in the Health Sector 20 Box 4: Variations in Premium Rates, Eligibility Criteria and Benefit Packages in Morocco 33 TABLES Table 1.1: Basic Health Indicators, MNA, 2004./5 6 Table 1.2: Total Fertility Rate, Select Countries, 1980 vs 2005 7 Table 1.3: Urban Rural Inequalities in Health, 2004 11 Table 3.1: Macroeconomic Projections, Morocco, 2006-2011 30 iii FIGURES Figure 1.1: Trends in Life Expectancy, Morocco, 1995-2004 6 Figure 1.2: Global Trends Analysis, IMR and U5MR, 2005 7 Figure 1.3: Percentage of Life Years Lost due to Premature Mortality, Morocco 1992 8 Figure 1.4: Causes of Mortality in Morocco, 2002 8 Figure 1.5: Projected Trends in Life Years Lost, Morocco, 2005-2030 8 Figure 1.6: Prevalence of Main NCD Risk Factors in Morocco, 2000 9 Figure 1.7: Regional Distribution of Poverty in Morocco, 2004 9 Figure 1.8: Child Mortality by Wealth Quintile 10 Figure 1.9: Prevalence of Underweight in Children Under-five Wealth Quintile 11 Figure 1.10: Adolescent Fertility Rate by Wealth Quintile 11 Figure 1.11: Social Determinants of Child Mortality in Morocco 12 Figure 1.12: Disparities in Health Seeking Behavior 12 Figure 1.13: Poverty and Sick Child Care by Health Professionals 13 Figure 1.14: Poverty and Perinatal Care by Health Professionals 13 Figure 1.15: Utilization of Health Facilities by Quintile – Public vs Private 13 Figure 1.16: Utilization of Health Facilities by Quintile – Public vs Private (Male Population only) 14 Figure 1.17: Utilization of Fealth Facilities by Quintile – Public vs Private (Female Population only) 14 Figure 1.18: Inequalities in Access to Primary Health Care 14 Figure 2.1: Institutional and Functional Linkages between Main Stakeholders in Health Care 17 Figure 2.2: Functional Segmentation in Health System Governance 19 Figure 2.3: Regional Comparison of Total Health Expenditure as Percentage of GDP, 2004 21 Figure 2.4: Regional Comparison of Per Capita Health Expenditure, 2004 21 Figure 2.5: Global Trend in Total Health Expenditure, 2004 21 Figure 2.6: Global Trend in Total Health Expenditure, 2004 (per capita GDP in PPP) 21 Figure 2.7: Global Trend in Government Expenditure on Health, 2004 22 Figure 2.8: Global Trend in Government Expenditure on Health, 2004 (per capita GDP in PPP) 22 Figure 2.9: Health Financing in Morocco 1998-2001 22 Figure 2.10: Global Trend Analysis of Out-of-Pocket Health Expenditure, 2004 23 Figure 2.11: Out-of-Pocket Health Expenditure and Fiscal Capacity, 2004 23 Figure 2.12: Gradient in the Choice and Use of Health Services by Expenditure Quintiles 23 Figure 2.13: Private Health Expenditures in Morocco 24 Figure 2.14: Per Capita Health Expenditures of the Poor 24 Figure 2.15: Distribution of Public Subsidy on Health by Type of Service and Quintile 26 Figure 2.16: Distribution of Public Subsidy on Health by Type of Service and Poor/Non-Poor 26 Figure 2.17: Distribution of Public Subsidy on Health by Type of Service and Urban/Rural 26 Figure 2.18: Budgetary Allocations for Public Hospitals, 2005 27 Figure 2.19: Comparison of Bed Occupancy Rates (BORs) in MENA 1995-2005 28 Figure 3.1: Human and Physical Resources in Morocco, 2005 29 Figure 3.2: Health Financing in Morocco, 2005 30 Figure 4.1: Health Status in Morocco Relative to Other Low- and High- Middle Income Countries 37 in MENA and Other Regions, Trends 1990-2005 Figure 4.2: Changing Role of the State in Health Care 38 iv ACRONYMS AND ABBREVIATIONS ALC Affectations longues et coûteuses M&E Monitoring and Evaluation ALD Affectations de longue durée MDG Millennium Development ALOS Average Length of Stay Goals AMI Assurance Maladie des MED Ministry of Economy, Indépendants MMR Maternal Mortality Ratio AMO Assurance Maladie Obligatoire MLSPP Ministry of Labor and Social ANAM Agence Nationale de l’Assurance Protection Maladie MOEF Ministry of Economy and BBP Basic Benefit Package Finance BOR Bed Occupancy Rate MOH Ministry of Health CAS Country Assistance Strategy MOI Ministry of Interior CHU Centre Hospitalier Universitaire MTEF Medium-term Expenditure CMB Couverture Médicale de Base Framework CMIM Caisse Marocaine NCD Non-communicable Diseases Interprofessionelle des Mutuelles NGO Nongovernmental CNOPS Caisse Nationale des Organismes Organization de Prévoyance Sociale NHA National Health Accounts CNSS Caisse Nationale de Sécurite OECD Organisation for Economic Co-operation Sociale and Development DALY Disability Adjusted Life Years PAGSS Programme d’Appui à la Gestion du Secteur DH Dirham de la Santé DHSA Direction des Hôpitaux et des PARL Public Administration Reform Development Soins Ambulatoires Policy Loan DPRF Direction de la Planification et PARP Public Administration Reform Program des Ressources Financières PER Public Expenditure Review DRG Diagnosis-related Rroups PFGSS Programme de Financement et de Gestion EDL Essential Drug List du Secteur de la Santé EC European Cooperation PHC Primary Health Care EIB European Investment Bank PIP Public Investment Program ENCDM Enquête Nationale sur la PPP Purchasing Power Parity Consommation et les Dépenses RAMED Régime d’Assistance Médicale des Ménages RDU Rational Drug Use ESSB Etablissements de Soins de Santé RH Reproductive Health de Base SEGMA Services de l’Etat gérés de manière EU European Union autonome FMIM Fonds mutuel interprofessionnel STP Standard Treatment Protocol marocain TB Tuberculosis GDP Gross Domestic Product U5MR Under-five Mortality Rate GLP good laboratory practice UN United Nations HDR Human Development Report UNDP United Nations Development Programme HECS Household Expenditure and UNICEF United Nations International Children's Consumption Survey Emergency Fund HIV Human Immunodeficiency Virus VHI Voluntary Health Insurance IMF International Monetary Fund WDI World Development Indicators IMR Infant Mortality Rate WHO World Health Organization INDH Initiative nationale pour le développement humain LBW Low Birth Weight MCH Maternal and Child Health v ACKNOWLEDGEMENTS This Policy Note was prepared by a team led by Enis Barış, principal author. Miho Tanaka provided research and technical assistance. Claudine Kader provided editorial assistance. The peer reviewers were George Schieber, Consultant, EASHD; Alexander Preker, Lead Economist, AFTH2; and Maris Jesse, Senior Health Specialist, ECSHD. The team received feedback from Akiko Maeda, HNP Manager, MNSHD, David Robalino, Senior Economist, MNSHD, John Langenbrunner, Senior Economist, MNSHD, Jean-Jacques Frere, Senior Health specialist, MNSHD and Sameh El-Saharty, Senior Health Specialist, MNSHD. The report has also benefited from discussions with Theodore Ahlers, Country Director, MNCO1, who provided overall guidance to the team. The author is grateful for their valuable support, advice and recommendations. This Policy Note draws heavily on several sector reviews, policy notes, project documents and technical reports prepared by World Bank staff, Government of the Kingdom of Morocco and donor, Unité de Santé Internationale, Université de Montréal, and UN agencies, notably the European Investment Bank (EIB), the European Cooperation (EC) and the World Health Organization (WHO) and discussions held with Senior Ministry of Health (MOH) and other government officials. Preliminary findings and recommendations were presented and discussed at a meeting held in the Ministry of Health in May 2007. The author gratefully acknowledges the cooperation, and constructive debate and critique provided by colleagues from the Unit and the MNA region, Ministry of Health, as well as to representatives of donor and UN agencies. EXECUTIVE SUMMARY Health and Demography: the Protracted Transition and the Unmet Needs 1. Since independence, Morocco has made impressive progress in improving health and life expectancy. Over the last 40 years there have been significant reductions in infant, under-five, and maternal mortality, and increase in life expectancy at birth from 47 to 70 years. 2. However, these achievements compare unfavorably with those of countries with similar socioeconomic development. The maternal mortality ratio (MMR) remains high—one of the highest in the MENA region and 45 times higher than the EU average (5 per 100,000 live births). Only 4.3 percent of pregnant women in the poorest quintile deliver their babies with the assistance of a doctor, 37 percent preferring delivering them at home. The under-five mortality rate (U5MR) is also high in Morocco—one of the highest in the MENA region and nine times higher than the EU average (6 per thousand live births). 3. Most determinants of high maternal and under-five mortality, two of the health-related Millennium Development Goals (MDGs), are imbedded in socio-structural inequalities in access to care. Being poor and living in rural areas where access to care is far from being acceptable are highly predictive of child and maternal mortality. For instance, in rural Morocco, maternal mortality is 43 percent higher. Children under the age of five of the poorest segment of the population are three times more likely to die as a result of an often easily treatable childhood illnesses or preventable injuries. 4. Morocco is in the midst of a demographic and epidemiologic transition at a time when major inequalities in health and access to healthcare persist. Beyond the MDG agenda, urbanization and changing lifestyles do affect people’s health behavior. As the prevalence of high blood pressure, smoking and obesity rise so does the prevalence of Non-communicable diseases (NCDs). Recent data shows that overall more Moroccans die of NCDs than in other causes. Circulatory diseases are the main cause of mortality, affecting men and women equally. As the population will gradually get older, while eating more, exercising less and smoking, it is inevitable that the ensuing burden of illness will tax health care system’s coping capacity and responsiveness, and increase costs. Responsiveness of the Health Care System; Meeting the Needs, Fulfilling the Expectations 5. At present, the publicly financed and run health care system does not meet healthcare needs of the majority of the Moroccans. Only half of the population uses health services when experiencing an illness, indicating that people who live outside big cities either cannot or will not pay for poorer quality services in rural health facilities. While in the short term limited use of healthcare services because of inability or unwillingness to pay may not significantly affect levels of morbidity and mortality resulting from non-communicable diseases, the impact is likely to grow exponentially in the next two decades. 6. The main reason for low responsiveness is the mismatch between the supply of health services and the demand for care. Most essential health services are either inaccessible to, or underutilized, by those who need them because of financial, social, physical and geographic barriers. While most of the unmet healthcare needs are in rural areas and amongst the poor, most well-endowed facilities, doctors and other health professionals are located in big cities. To make the matter worst, public funds does not follow the patient, but is directed to where the facilities and doctors are located. Consequently, the better-off, the urban and those with the right connections have easier access to care whereas the majority must pay out-of-pocket either to have better access to public providers or simply use the services of private providers where the quality is better. 1 7. System responsiveness could be improved at the margins by targeted programs. While it will take longer to alleviate socio-structural inequalities, Morocco could easily bring down the unacceptably high child and maternal mortality rates with well-funded programmes geared towards the needs of the rural poor for nutrition, immunization, and timely and proper treatment of childhood illnesses. Despite the paucity of data, the main causes of maternal deaths would be acute severe bleeding, eclampsia, unsafe abortion and obstructed labor, which could be prevented and/or properly treated if expecting mothers received proper antenatal care and the facilities were properly equipped and the staff well trained, all feasible and affordable in today’s Morocco. 8. Responsiveness could be further enhanced with pro-activity and foresight for developing, properly financing and implementing large-scale disease prevention and health promotion programs. The epidemiologic transition will require a different set of facilities and technology, and a different mix of social and medical skills and competence that need to be envisaged, planned and invested in without delay. To move forward, Morocco must adopt policies that increase government financing and improve allocation of public funds in line with its epidemiologic and demographic profile and the burden of risk factors and illness. 9. However, large-scale reforms are needed to make the health care system truly responsive in the future. Despite recent attempts by the government to expand population coverage, improve system governance, and increase the quality of care, Morocco’s health care system remains predominantly state owned and managed, yet highly fragmented. On one hand, the system is not truly pluralistic because of negligible participation of providers and consumers in system governance. On the other hand, the execution of all main healthcare functions are segmented across several government agencies, or applicable to different population segments. In addition, low and poorly allocated public outlays for health care result in inefficiencies in the allocation and use of public resources, as well as in high private out-of-pocket expenditures. If a publicly funded health insurance scheme is intended to provide universal coverage for an essential package of services, a significant restructuring of the existing institutional architecture and of the legislative and regulatory framework will be needed to make it a reality. An Agenda for Health Sector Reform 10. This note identifies three main issues and proposes a set of short- and longer-term policy measures for each (Please see the policy matrix at the end of the note for an integrated summary of all short and longer term policy measures). Equity - Implementation of the “Couverture Médicale de Base� 11. While targeted programs (TB, HIV/AIDS, MCH etc.) and mobile intervention strategies may improve access through increased supply and consequently help improve health outcomes, the solution, as amply recognized by the Government, is the achievement of universal coverage in an equitable and fiscally and financially sustainable manner. This will require, first and foremost, an agreement on the content of the Basic Benefit Package that RAMED will have to cover. Given the extensive amount of preparatory analytical and advisory work conducted thus far, what is needed is more than simply defining broad categories (e.g., inpatient care, or “affections de longues durées�) but rather adopting standard treatment and referral protocols and informing the beneficiaries to reduce ambiguity and therefore mitigate access problems and informal payments. 12. A second issue is the agreement on the eligibility criteria, and on finding optimal trade-offs between fairness in patient contribution and fiscal viability on one hand, and, on the other, ease of administration, enforceability and convenience for the clientele in getting in and out of the two categories (i.e., the poor and the vulnerable) and making the initial payments for the carte d’indigence and user fees. Once RAMED is up and running, and AMI-Inaya becomes fully functional, 2 harmonization of the premium rates, eligibility, benefit packages, reimbursement rates and co- payments should gradually be carried out for a “virtual� merger of all the insurance schemes. The harmonization process would also include the fee schedule that is negotiated with the providers. 13. Another parallel activity would be defining the role of private health insurance. Ideally, given the extensive “mutualisation“ of health insurance in both the private and public sector, one would expect that private insurance scope and coverage will be geared towards offering insurance packages to complement or supplement what is already covered rather than competing on the basis of the same package of services by various schemes. Therefore, the competition will not be on the content, but rather on the quality and price of the complementary package. Good governance – Segmentation of Stewardship, Financing and Service Provision 14. A sine qua non for good governance is the functional segmentation of the main roles and responsibilities of the Ministry of Health, ANAM (RAMED) and the AMO implementing agencies. A good start would be the issuance of the Strategy document “Santé Vision 2020� which - it is hoped – will set the stage for the necessary restructuring of the Ministry of Health from being mainly a financing agent – albeit through the Ministry of Finance – and a provider of health services, to becoming a policy making, planning, standard setting, regulating, enforcing, intelligence gathering and evaluating agency. Once there is an agreement on its renewed mandate towards “more steering and less rowing�, the MOH would have to restructure its organization set-up, create new units and recruit and/or train new staff to effectively fulfill its new functions. In parallel, an effort would also be needed to complete the on-going regionalization process and making sure that the transfer of authority and accountability to the new regional departments will not be purely administrative, but rather would hold them to account for due diligence in financing and delivery of health programs. As such, the recently instituted budget based programming is in the right direction provided that there will be a rigorous and external evaluation mechanism for proper assessment of their effectiveness. 15. Three other policy measures need to be undertaken in tandem: (i) the autonomization of public hospitals with full financial and managerial autonomy as a prelude to subsequent contracting arrangements with the payers; (ii) revision of stature of the professional associations to redefine and clarify their roles in licensing, and certification of health workers and to allow them formal participation in major policy and administrative personnel decisions; and (iii) issuance of a patients’ rights law for consumer protection against medical malfeasance. Allocational and Technical Efficiency 16. Improved access to care by the poor will inevitably put pressure on the supply side. Morocco’s present endowment in physical, technological and human resources barely copes with the existing low level and intensity demand for health care - approximately 0.6 visits per capita per year – and that at the expense of a shift in resource use away from ESSBs towards regional hospitals and CHUs. This report advocates for the preparation and adoption of a “carte sanitaire� which would need to also consider prospects for private sector investment outside Rabat and Casablanca and obtain consensus and adopt the human resources development strategy that has recently been drafted. Hopefully, with the concurrent progress in rural development, and through the “Initiative nationale de développement humain� there will be a significant improvement in poverty, maternal education and child schooling which also will contribute to improved health outcomes. Regardless, investment in rural health facilities (ESSBs) and finding the right financial and professional levers to match the supply of good quality essential health care services such ante- and peri-natal care, integrated management of childhood illnesses, immunization and micro-nutrient supplementation with a demand which need to be induced by proper public information education and communication will be required. 3 17. A complementary measure would be to develop and adopt a resource allocation formula, weighted by demographic and epidemiologic profile of the regions as a basis for the contrat- programmes with the regional authorities. Such a measure, if properly designed and executed, is very likely to improve efficiency in the allocation and use of resources. A number of studies would need to be conducted first, such as a second Burden of Disease study and a Risk Factor study with large enough samples for dis-aggregated assessment of the burden at the communal level. Adoption of the formula will also help with implementation of the Medium-Term Expenditure Framework in the longer run. Additional measures may include the issuance of financial and non-financial incentive packages to entice the deployment of health personnel to underserved areas and a new policy for price setting and reimbursement of generic drugs. 18. At a more micro level, the adoption of standard treatment protocols for improved technical quality of care, a new policy on rational use of drugs and pay-for-performance measures for physicians in the short run would also be valuable in increasing technical efficiency. In the longer term, however, other more expansive measures such as the institutionalization of accreditation of hospitals and health care technology assessment, and above all ANAM’s ability to constantly monitor and audit technical quality and appropriateness of care provided by the contracting provider would be essential as a basis for moving towards an output-based (i.e., case mix, diagnosis-related groups, etc) payment modalities. 19. All these options carry significant political risks and institutional capacity challenges, more so than fiscal constraints. However, with strong leadership and a vision for the future as well as the adoption of a consensual process fully involving all public agencies and representatives of the providers and population groups, there is no reason why these policy measures cannot be undertaken. What is crucial is the realization that the health sector is in dire need of investment, mostly in its workforce but equally importantly in its “info-structure� to generate and manage health information for sound decision making. A Way Forward 20. The first step is for the MOH to take the lead in managing the reform process by redefining its vision, mission, mandate, roles and responsibilities, all of which would form the basis of the draft document Santé-Vision 2020. Its completion will require a consensus-building exercise among all stakeholders in the healthcare system and the preparation of an implementation plan for reform, including the costing of necessary inputs. 21. The preparation and the issuance of the Santé-Vision 2020 should have the backing of the Royal Court and be supported by an interagency steering committee. The array of options presented therein should be fed back to all stakeholders to build consensus on their specific content and, equally important, to facilitate agreement on the timing, sequencing and financing of reform elements. 22. The proposed reform agenda is admittedly ambitious in its scope and reach. The issue is whether the government has the capacity and/or the political will to follow through and deliver on its commitments. Granted, some of the reform initiatives would depend largely on the availability of additional resources. Others would require difficult policy decisions. Ultimately, success will depend on how central will the goal of building an equitable and responsive healthcare system become on Morocco’s human development agenda. 4 INTRODUCTION: SCOPE AND PURPOSE OF THE POLICY NOTE 1. This Policy Note aims at providing policy makers and senior government officials with a comprehensive yet internally coherent policy reform framework as one input to the ongoing efforts to develop their own vision of the future for a high performance health sector in Morocco. 2. The Note comprises four chapters. Chapter 1 provides an overview of health and healthcare in Morocco. Its focus is on documenting inequalities in health, or, more specifically, the causes and consequences of the structural and social determinants of ill-health and access to health care in a context of demographic and epidemiological transition and significant distributional inequalities in human, financial and physical resources across the country. It has three sections: (i) a description of the health and demographic status and their evolution over time; (ii) an assessment of health and poverty and of the resultant inequalities as a result of its distal and proximal determinants; and (iii) a synthesis of patterns and trends in supply of health care since Independence and the recent attempts at reforming the health care system. 3. Chapter 2 builds on the findings and observations made in the previous chapter to document and highlight main sectoral issues and preoccupations with regard to four desiderata: good governance; equity in access to care; efficiency in the allocation and use of limited resources; and population and provider satisfaction. The emphasis is on governance, financing and resource allocation and use. The delineation of the roles and responsibilities of the State at the central and sub- national levels, and with its various payer and regulator agencies vis-à-vis key functions in health care (policy making, resource allocation, management, regulation etc.) is one issue that is highlighted. Another is the role that providers (professional associations, representatives of the private sector) and the citizens play towards a more pluralistic, transparent and accountable governance model. 4. The remit of Chapter 3 is the “what� question, or the content of the reform agenda, focusing on the expansion of population coverage and improved governance with a view to reducing inequities while safeguarding overall efficiency and fiscal sustainability. Chapter 4 tries to answer the “how� question, by proposing a comprehensive, integrated and hopefully internally coherent policy matrix to highlight the interconnectedness of policy measures. The importance of sequencing the short and longer term policy measures on an admittedly ambitious reform agenda tackling at once the shortcomings in equity, efficiency and governance is emphasized. 5. This Policy note is expected to advise and assist: (i) the Royal Cabinet and the Council of Ministers in their deliberations vis-à-vis the evolving role of the State and the private sector in health care and the delineation of the functional responsibilities of the MOH and para-statal agencies; (ii) the Ministry of Health in its attempt to redefine its own role and functions in a more pluralistic healthcare system and restructure its central and sub-national entities; and (iii) other national (e.g., private providers, professional associations, trade unions, consumer advocates, etc.) and international (UN agencies and donors) partners in seeking and building consensus over what needs to be done and how to do it for a more effective and vigorous partnership with the Government of the Kingdom of Morocco in these times of rapid socioeconomic transition. It is our sincere hope that it will play a role in implementing the proposed reform policy and strategies in a timely and well-sequenced manner to satisfy the aspirations for a high performance yet affordable health care system in Morocco. 5 CHAPTER 1: HEALTH AND HEALTH CARE IN MOROCCO – AN OVERVIEW 1.1. Health and Demography 1. Since independence, improvement in health outcomes has been impressive. Over the last 40 years there have been significant reductions in infant, under-five, and maternal mortality, and increased life expectancy at birth from 47 to 71 years1 (Figure 1.1). Morocco is expected to achieve 2/3 reduction in infant mortality and ¾ reduction in maternal mortality in 2015, the target date for the attainment of Millennium Development Goals (MDGs) (see Annex 1). Figure 1.1: Trends in Life Expectancy, Morocco, 1995-2004 74 72 70 68 Male Female 66 Both 64 62 60 1995 2000 2004 Source: World Bank HNP stats Data Query 2. Despite significant progress, however, Morocco’s health achievements remain below those of countries with a similar level of socioeconomic development (Table 1.1 and Figure 1.2). Morocco’s overall performance in human development remains below its global ranking by economic development and growth. 2 Morocco has the highest maternal mortality in the region at 227 per 100,000 live births. Similarly, the infant mortality is amongst the highest in region. According to the WHO’s World Health Report 2000, Morocco was ranked 111th out of 191 countries in terms of disability-adjusted life years (DALYs) lost (See Annex 2 for rankings of Morocco and comparable countries). Table 1.1: Basic Health Indicators, MNA, 2004/5 Countries Life Expectancy Infant Mortality Rate Maternal Mortality at Birth (per 1,000 live births, Ratio (per 100,000 (in years, 2004) 2004/5) live births, 2004/5) Algeria 71 30.4 96.8 Morocco 71 40.0 227.0 Egypt 68 20.5 62.7 Saudi Arabia 71 19.1 12.0 Lebanon 70 18.6 88.4 Tunisia 72 20.6 48.0 Kuwait 77 8.2 4.0 Jordan 71 22.0 40.3 Oman 74 10.3 15.4 Source: WHO-EMRO 2005. 1 Please see “le rapport thématique sur le système de santé et qualité de vie� prepared in the context of the Moroccan initiative “50 Ans de Développement Humain – Perspectives 2025.� 2 Morocco is ranked 108th in terms of GDP per capita PPP, but 123rd in terms of Human Development Index (Source: UNDP’s Human Development Report 2006). 6 Figure 1.2: Global Trend Analysis, IMR and U5MR, 2005 Panel A: Infant Mortality Rate, 2005 Panel B: Under-five Mortality Rate, 2005 250 250 y = 60452e-2.0998x y = 167166e-2.299x R2 = 0.8154 R2 = 0.8193 200 200 Mortality (per 1,000 live births) Mortality (per 1,000 live births) 150 150 Under Five Infant 100 Morocco 100 Morocco 50 50 0 0 100 1000 10,000 100,000 100 1000 10,000 100,000 Per capita GDP, PPP, 2005 Per capita GDP, PPP, 2005 Source: World Development Indicators 2007, Source: World Development Indicators 2007, UNICEF State of the World Children UNICEF State of the World Children 3. Like other countries in the region, Morocco is going through demographic transition characterized by decreasing fertility and increasing life expectancy, leading to a youth bulge and pending shift in the age composition. As a result of active reproductive health policies, the total fertility rate dropped significantly (Table 1.2), albeit with large differentials between the lowest and highest income quintiles (3.3 versus 1.9 children per woman) and urban and rural populations (2.1 versus 3.0). Assuming a net reproduction rate of 1 in 2010, the population is expected to reach 39.7 million in 2025. The life expectancy will reach 73 years for both sexes, and the dependency ratio will decrease from 57 (in 2005) to 45.5 (Please see Annex 3 for an overview of the demographic profile in Morocco). Table 1.2: Total Fertility Rate, Select countries, 1980 vs. 2005 1980 1990 2000 2005 Morocco 5.6 4.0 2.6 2.4 Algeria 6.8 4.6 2.7 2.4 Tunisia 5.2 3.5 2.1 2.0 Egypt, Arab Rep. 5.4 4.3 3.4 3.1 Jordan 7.0 5.4 3.8 3.3 Syrian Arab Republic 7.3 5.2 3.7 3.2 Turkey 4.3 3.0 2.6 2.2 Iran, Islamic Rep. 6.6 4.8 2.3 2.1 Source: World Development Indicators 2007. 4. The demographic transition, overall socio-economic development and improved quality of life led to an epidemiologic transition. Demographic transition and reduced overall mortality brought an increase in youth and adult population, representing both an opportunity and a challenge to social and economic growth,3 but also to the health care system as a consequence of the ensuing epidemiologic transition. 4 The first burden of disease study conducted in early 1990s showed an increase in the NCDs and injuries (Figure 1.3). In 2003, undefined symptoms and signs as a disease category was reported as the cause of 34.7 percent of all deaths, followed by diseases of the cerebro- vascular system (18.1 percent), tumors (7.1 percent), endocrinological disorders (5.8 percent), and respiratory diseases (5.1 percent) accounting for about two-thirds of all deaths. Since then there has been steady increase in the share of NCDs in overall mortality, mostly as a result of an increase in the 3 In 2003, the unemployment rate in urban areas was 19.3 percent. In 2006, the youth (15 to 29 years of age) constituted 42.5 percent of the population whereas the elderly (65 y and above) accounted for 4.8 percent of the total population. 4 It is a protracted epidemiological transition given the continuing burden of communicable diseases along with the increasing burden of non-communicable diseases (NCDs) and injuries. In 2005, there were 2,221 cases of measles, 1099 of meningitis, 1497 of typhoid fever and over 26,000 of TB. In 2004, only 71 percent of the population had sustainable access to improved water, and 76 percent to improved sanitation (WHO EMRO Country Profile Morocco, 2005). 7 prevalence of cardiovascular diseases which account for about 60 percent of adult mortality (Figure 1.4). Non-Communicable Diseases will increasingly account for a large share of the Burden of Illness. It is expected that the trends will continue with continuous increase in the share of NCDs and injuries in the overall burden of illness in Morocco (Figure 1.5) due to increased urbanization, 5 changing lifestyles (Figure 1.6), and a decline in the prevalence of communicable diseases. Figure 1.3: Percentage of Life Years Lost due to Premature Mortality, Morocco, 1992 60 50 40 Communicable 30 NCDs Injuries 20 10 0 Male Female All Source: MOH, Morocco, 1992 Figure 1.4: Causes of Mortality in Morocco, 2002 Panel A: All Causes Panel B: Non-Communicable Diseases Source: WHO –EMRO, 2002 Figure 1.5: Projected Trends in Life Years Lost, Morocco, 2005-2030 70 60 50 2005 40 2015 30 2030 20 10 0 Communicable NCDs Injuries Diseases Source: WHO-EMRO, 2005. 5 Between 1994 and 2003, the urban population increased by 28.5 percent vs. 1.5 percent in rural areas. As of 2002, 56.6 percent of the population lived in urban areas. While poverty is largely rural (25 percent vs. 12 percent in urban areas), it is becoming increasingly urbanized. 8 Figure 1.6: Prevalence of Main NCD Risk Factors in Morocco, 2000 40 35 HBP BP>=140/90 mm HG (%) 30 Diabetes Glucose>= 25 1,26g /l (%) High cholesterolemia 20 TC>=2g/l (%) 15 Obesity BMI>= 30 (%) 10 Smoking (%)* 5 0 All Males Females Urban Rural Source: Tazi, M.A., Lahmouz, F., Abir-khalil,S., Chaouki, N., Arrach, M.L., Charqaoui, S., Srairi, J.E., Majhou, J. Enquête nationale sur les facteurs de risque des maladies cardiovasculaires – 2000. Dans Ministère de la santé du Maroc, DELM. Bulletin épidémiologique no 53-54. 1er et 2e trimestres 2003 1.2. Poverty and Inequalities in Health and Health Care; Patterns and Trends 5. Despite recent decline, poverty is still high with a significant urban rural gradient. Between 1994 and 2004 there was a reduction of 14 percent in the national poverty rate (from 16.5 percent to 14.2 percent) albeit with a significant differential between rural (22 percent) and urban (7.9 percent), maily due to the reduction in rural areas of only 4 percent during the same time period vs a reduction of 24 percent in urban areas. Overall, out of 1298 communes only 30 has a poverty rate less than 5 percent while 348 have more than 30 percent. At the regional level, three regions with the highest poverty rates are Massa Dra (18,9 percent), Marrakech-Tensift-Al Haouz (19,2 percent) and Meknès Tafilalet (19,5 percent), albeit with significant differentials within the regions between the urban and rural populations. At the provincial level, it varies between 2,4 percent in Rabat prefectorate and 33,6 percent in the province of Zagora (Figure 1.7). An additional 25 percent of the population who live at or below 50 percent above the poverty line is considered “economically vulnerable� to illness, natural disasters, or unemployment. Poverty, both as a cause and consequenct of ill-health and lack of education has a strong gender gradient. About 2.5 million children, a majority of whom are rural girls, do not attend school, and thus are more likely to marry at a younger age, perpetuating the vicious cycle of poverty. In rural areas, 83 percent of women are illiterate (Box 1). Figure 1.7: Regional Distribution of Poverty in Morocco, 2004 25,0 % 20,0 % 15,0 % 10,0 % 5,0 % MARRAKECH 0,0 SOUSS BOULEMAN % BAT OUARDIGHA DOUKKAL MÉKN A-AL GER NTAL TAN TADLA- ORIE ESSEMERA TAZ GRAN RA AZILAL CASA EDDAHE GUELMIM- A ABDA CHAOUIA LAAYPUNE- BOUJDOUR ES OUED CHRARDA BNI FES- EL GHARB- E B Source: Haut-Commissariat au Plan. Morocco, December 2005 9 Box 1: Poverty, Gender, Education and Health Acute or chronic illness, disability of a family member or death of a breadwinner limits upward mobility and is a frequent catalyst of downward mobility. Temporary illness or longer term disability can seriously disrupt the income of people whose work depends on their good health and physical strength. Households experience downward mobility when illness forces them to sell off assets to cover costs of treatment and/or transport to distant urban hospitals. Although the non-poor also experiences illness and disability, they either have health insurance or sufficient savings to pay for treatment without impoverishing the household. Poverty also has a strongly gendered character - 2.5 million children, a majority of whom are rural girls, do not attend school. Gender indicators in literacy and health, especially in rural areas, are among the worst in the region. In rural areas, 83 percent of women remain illiterate. Women are particularly vulnerable to impoverishment and downward mobility when their husbands become disabled or ill. This effect is more noticeable in the poorest, agriculture-dependent and traditional communities. It is less marked in the urban and/or more prosperous rural communities that offer more economic opportunities for women (for example in the service sector), and where it is more accepted and common for women to work outside the home. Women and girls are particularly vulnerable to the impacts of poor education and health services. In communities without schools, it is generally the poorest families who refuse to send their children, especially girls, far to study. Lack of health adequate health facilities, as in Khalouta, Ait Hammi, Ait Messaoud and Igourramene Tizi particularly hurt women. Many are reluctant to consultant male practitioners, and lack of local childbirth facilities, combined with poor roads and expensive transport, put them at risk during childbirth. Excerpt from: World Bank: Kingdom of Morocco; Moving out of Poverty, March 2007 6. High poverty rates in Morocco are inducive to poor health outcomes. 6 Under-five mortality for the poorest quintile is more than twice the rate for the richest quintile (Figure 1.8). The proportion of underweight children in the poorest quintile is more than four times higher than in the wealthiest (Figure 1.9). The adolescent fertility, both a cause and a consequence of poverty, is also four times higher in the lowest quintile compared with the wealthiest (Figure 1.10). Figure 1.8: Child Mortality by Wealth Quintile (per 1,000 live births) 80 77.6 65.5 62.2 60 53.1 46.7 40 37.3 36.8 IMR 33.4 26.1 20 U5MR 24 0 U5MR Lowest 2nd IMR 3rd 4th Highest Source: Davidson R. Gwatkin et al (2005) Socioeconomic differences in health, nutrition and population in Morocco, derived from DHS 2003/04 data. 6 For a detailed analysis of inequalities in health by wealth quintiles see Annex 4. 10 Figure 1.9: Prevalence of Underweight in Figure 1.10: Adolescent Fertility Rate(*) by Children Under Five by Wealth Quintile(*) Wealth Quintile 14 13.2 60 50.7 12 50 44.3 10 35.7 8.3 40 7.7 8 6.9 30 6 21 20 4 2.9 12.5 2 10 0 0 Lowest 2nd 3rd 4th Highest Lowest 2nd 3rd 4th Highest (*) Percent of Moderate Underweight (*) Annual number of live births per 1,000 girls aged 15-19 Source: Davidson R. Gwatkin et al (2005) Socioeconomic differences in health, nutrition and population in Morocco, derived from DHS 2003/04 data. 7. There also is a large gradient in health outcomes between the urban and rural populations. Life expectancy in rural Morocco is, on average, six years shorter, mainly due to higher infant, under-five and maternal mortality, pointing out to unmet health care needs (Table 1.3). Maternal mortality, one of the eight MDG goals, is 43 percent higher in rural areas. Finally, the roles of gender, area of residence, mother’s education and poverty in explaining the variation in under-five mortality are higher in Morocco than their averages for five comparator countries, pointing out to the role of social determinants of health despite the existence of effective interventions to reduce their effects (Figure 1.11). Table 1.3: Urban Rural Inequalities in Health, 2004 Indicators Urban Rural National Total fertility rate 2.1 3.0 2.5 Crude birth rate 18.8 22.6 20.4 Crude death rate 4.7 6.7 5.5 Population growth rate 1.4 1.6 1.5 Infant mortality rate 33 55 40 Under-five mortality rate 38 69 47 Neonatal mortality rate 24 33 27 Post-neonatal mortality rate 9 22 13 Maternal mortality ratio 187 267 227 Life expectancy at birth 73.4 67.4 70.3 Source: Ministère de la Santé, La santé en chiffres 2004 et EPSF 2003-2004. 11 Figure 1.11: Social Determinants of Child Mortality in Morocco Wealth quintile s L/H Ratio 3 2.5 2 1.5 1 0.5 Mothe r's Education Q uintile s Ratio 0 Urban/Rural Ratio Male /Fe male Ratio Morocco Reference country average (*) Source: World Health Report 2007 (*) The unweighted average of the sum of ratios for each indicator in Colombia, Egypt, Jordan, Tunisia and Turkey. 8. Inequalities in socioeconomic and geographic access to health care are the most important proximal determinants of mortality differentials, especially for infant, child, and maternal mortality. The poor, especially the urban poor, are less likely to seek healthcare when ill as a result of inability, or unwillingness to pay (Figure 1.12), indicating limited social, economic and geographic access,7 and responsiveness, 8 especially to the basic health and care needs of the rural and the poor (Figure 1.13 and 1.14). Figure 1.12: Disparities in Health Care Seeking Behavior 80% 70% 60% 50% Seeking 40% Treatment 30% 20% 10% 0% Urban poor Rural poor Urban non-poor Rural non-poor Source: LSMS 1998/99, Ministry of Health (2000), and WB Staff Calculations 7 As of 2002, 85 percent of the population had access to primary health care, 65 percent in rural and 100 percent in urban areas (Source: WHO EMRO Morocco Country Profile). 8 According to the WHO World Health Report 2000, Morocco ranked 125th out of 191 countries in equitable access to care (see Annex 2). 12 Figure 1.13: Poverty and Sick Child Care by Health Figure 1. 14: Poverty and Perinatal Care by Professionals Health Professionals 60 100 50 80 40 60 30 Fever 40 Antenatal Care 20 Diarrhea 20 Delivery Assistance 10 ARI 0 ARI L o w e st 0 Antenatal Care 2nd 3 rd 4 th L o w est Fever H ig h e st 2nd 3 rd 4 th H ig h e st Source: Davidson R. Gwatkin et al (2005) Socioeconomic Source: Davidson R. Gwatkin et al (2005) Socioeconomic differences in health, nutrition and population in Morocco, differences in health, nutrition and population in Morocco, derived from DHS 2003/04 data. derived from DHS 2003/04 data. 9. The urban and those who can afford it prefer using private providers whereas the rural and the urban poor rely on public health centers, dispensaries and polyclinics. Only 30 percent of the wealthiest quintile use public providers compared to 70 percent of the poorest quintile (Figure 1.15). Amongst the poor, men use public health facilities more often than women, especially in rural areas (Figures 1.16 and 1.17). There is an implicit hierarchy in the levels of care across the public delivery network. While the Primary Health Care (PHC) is in place, access to most essential services are constrained, especially for the poor and the rural, as a result of limited availability of well- endowed PHC facilities, inadequate distribution of the health workforce, lack of coordination and referral system between levels of care, and perverse incentives in full-time work in the public sector for qualified specialists (Figure 1.18 and Box 2). Figure 1.15: Utilization of Health Facilities by Wealth Quintile – Public vs. Private 80% 70% 60% 50% 40% 30% 20% 10% 0% Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 Dispensary, Health Centers Public Hospitals Other public Private office Other private Public Total Private Total Source: LSMS 1998/99, Ministry of Health (2000), and WB Staff Calculations 13 Figure 1.16: Utilization of Health Facilities by Wealth Quintile – Public vs. Private (Male Population Only) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Urban Poor Rural Poor Poor Total Urban Non-poor Rural Non-poor Non-poor Total Dispensary, Health Centers Public Hospitals Other public Private office Other private Public Total Private Total Source: LSMS 1998/99, Ministry of Health (2000), and WB Staff Calculations Figure 1.17: Utilization of Health Facilities by Wealth Quintile – Public vs. Private (Female Population Only) 80% 70% 60% 50% 40% 30% 20% 10% 0% Urban Poor Rural Poor Poor Total Urban Non-poor Rural Non-poor Non-poor Total Dispensary, Health Centers Public Hospitals Other public Private office Other private Public Total Private Total Source: LSMS 1998/99, Ministry of Health (2000), and WB Staff Calculations Figure 1.18: Inequalities in Access to Primary Health Care Panel A: Access to PHC – Overall Panel B: Inequalities in Access to PHC % infants immunized against Measles immunization measles coverage L/H ratio 100.0 3.5 80.0 3.0 2.5 60.0 2.0 40.0 1.5 % births attended by skilled % children treated for diarrhea 1.0 20.0 professional 0.5 Measles immunization 0.0 Births attended U/R ratio 0.0 coverage U/R ratio % women with at least 1 antenatal % children treated for ARI care visits Births attended L/H ratio Morocco Reference country average (*) Morocco Reference count ry average (*) Source: World Health Report 2007 Source: World Health Report 2007 14 Box 2: Inequalities in Access to Primary Health Care in Morocco, 2004 Morocco has a large network of primary health care facilities, called ESSBs (Etablissements de soins de santé de base). In 2004, there were 2510 ESSBs, or one per 11,909 inhabitants, with a higher ratio in rural areas (1862 ESSBs, or one for 8,900 inhabitants, compared to 649 ESSBs in urban areas, or one per 20,900 inhabitants). However, this does not translate into full geographic, socio-organizational and economic access to quality and appropriate health care. According to the Département des soins ambulatoires et hospitaliers (DHSA), in 2003 about half of the population lived less than 3 km from an ESSB, 46 percent lived farther than 6 km, and 25 percent lived more than 10km away from one. In the same year, most ESSBs did not have a physician, and 258 ESSBs closed from lack of personnel.9 Only 30 percent of the general practitioners on the MOH payroll worked in rural ESSBs. The nurse population ratio varied from 0.29 per thousand in Doukkala Abda to 1.24 per thousand in Laayoune, three to five times lower than in comparable countries. There was a large variation in the ESSB population ratio across the 16 regions, from 4,936 in Guelmim-Essemara to 17,049 in Doukkala Abda, with many ESSBs not having any physician. These data excluded the developed regions of Casa and Rabat where most health care is either provided in CHUs or private settings, obviating the need for ESSBs as a result of higher insurance coverage and income and education levels. The per capita median annual number of visits to a physician is 0.6 (2005 data), very low by international standards. Less than 10 percent of pregnant women received full prenatal care, compared with 40 percent in Egypt and more than 70 percent in Jordan and Tunisia. Only 63 percent of births were assisted by a health professional, compared with 74 percent in Egypt, 90 percent in Tunisia, and 100 percent in Jordan, with high urban-rural (2.2, compared with 1 in Jordan and 1.7 in Tunisia) and richest-poorest (3.2) ratios. 1.3. Patterns and Trends in Supply of Health Care 10. The State plays a predominant role in health care financing, organization and delivery. At independence, Morocco opted for a tax-based and state-run system with public ownership, management and financing of health facilities and providers, and public delivery of health services. The evolution of the health care system is characterized by increasingly expanding and centralizing the roles and responsibilities of the Ministry of Health (MOH) across all functions. Three distinct phases mark this evolution: (i) Phase I, from independence in the early 1960s to the 1980s, characterized by heavy investment in infrastructure and expansion of the number of health professionals; (ii) Phase II, from the 1980s to the late 1990s, characterized by hospital-centered investment and expansion of targeted health programs; and (iii) Phase III, from the late 1990s to date, characterized by a debate on how to reform the system to increase population coverage and improve efficiency and quality of care.10 11. Continuous investment in health facilities and training of health professionals has resulted in better health outcomes. Coverage of, and access to, essential health services such as immunization and primary health care have also improved. As a consequence of heavy public investment, the MOH emerged as the predominant force in charge of financing, managing, and operating the publicly-owned health care delivery network of facilities. A parallel sub-sector of private facilities and practitioners gradually built up to compete on quality, at the least for wealthier and more educated urban dwellers.11 12. Over the last five years the government has expanded population coverage, improved system governance, and increased quality of care. As part of its drive to reduce poverty through the National Human Development Initiative (Initiative Nationale de Développement Humain, INDH), the government enacted a law in 2002 on “basic health care coverage� (Couverture Médicale de Base, CMB). The Law foresaw the creation of two insurance schemes, a compulsory health insurance scheme, or AMO (Assurance Maladie Obligatoire) and a medical assistance scheme or RAMED (Régime d’Assistance Maladie aux Economiquement Démunis, or more recently, Régime d’Assistance Médicale). In addition, a new agency was established, the Agence Nationale d’Assurance Maladie (ANAM), to regulate CMB and manage RAMED. While the AMO has operated 9 The number of closed ESSBs has since been reduced to 197. 10 From “le rapport thématique sur le système de santé et qualité de vie� in the context of Morocco’s initiative “50 Ans de Développement Humain – Perspectives 2025.� 11 In 2004, there were almost as many doctors working in the private sector (7,644) as in the public sector (9,544). 15 since September 2005, covering civil servants (Caisse Nationale des Organismes de Prévoyance Sociale or CNOPS)12 and those formally employed in the private sector (Caisse Nationale de Sécurité Sociale, CNSS), the regulatory and institutional mechanisms necessary to render RAMED operational are still under preparation. 13. Decentralization of health services management at the regional level is progressing, albeit slowly. Sanitary regions were created that do not follow administrative borders, but are based on socioeconomic, geographic, and health criteria. A successful pilot in the Oriental region had financial and technical support from the EU to upgrade facilities, build a management information system, and train health professionals; but scaling it up has been uneven, partly from limited capacity, but also because the central level resisted transferring power and responsibilities. 14. Other reforms are in process. These include la réforme hospitalière, financed first by the World Bank, and more recently by the European Investment Bank, to improve physical and technical infrastructure in select hospitals and pilot new planning, management, and hospital information tools for improved quality and efficiency. 15. These reforms have been in the right direction. The government and MOH need to complete piloting programmatic and instrumental reforms such as decentralizing system management in the Oriental region and adopting tools developed to enhance hospital autonomy, and complete their evaluation. Otherwise, the extensive preparatory technical assistance provided to MOH through PFGSS and PAGSS 13 for expanding these reforms will become obsolete without any documented impact on access to care, service quality, system governance, or efficiency. 16. “Santé, Vision 2020� is likely to boost the reform process and enhance coordination. Many financing reforms, such as establishing AMO and RAMED, were undertaken after policy and legislative initiatives to expand the CMB, rather than being conceived or planned in harmony with broader reforms encompassing system governance, human resources development, and the role of the private sector. Cognizant of these shortcomings, the government launched, at first, an initiative entitled “Santé, Vision 2015� which encompassed 11 strategic tracks.14 This was soon to be followed by another impressive effort, called “Santé, Vision 2020�, to seek and build consensus amongst all public, non-governmental and private stakeholders on the underlying principles of the healthcare system in Moroccco as “equity�, “solidarity� and “participation and responsibility�. The latter, made public very recently, reiterates that all citizens should have access to healthcare according to their needs and not their ability to pay, and that the services should be of quality, effective, and centered to the patient. It defines eight strategic tracks (“Axes stratégiques�) 12 CNOPS does not cover all civil servants. It is a federation of eight “mutuelles,� each associated with a state enterprise, but other state enterprises are not affiliated with CNOPS, notably Royal Armed Forces, Royal Air Maroc and State Tobacco Company. 13 PFGSS and PAGSS are the Bank-financed Projet de Financement et de Gestion du Secteur de la Santé and the EU- financed Projet d’Appui à la Gestion du Secteur de la Santé, respectively, the two largest health projects through which MOH received technical support and financing for infrastructure. 14 They include: (i) reinforcement of disease prevention, consolidation of programs to control commuicablediseases and development of programs to combat Non-Communicable Diseases; (ii) improved equity and reduced disparities in access to care and resource allocation; (iii) reduction of shortage in health workforce and revalorization of human resources (iv) promoting public health; (v) increased financing; (v) improved governance; (vi) improved resource management; (vii) expanded and financially sustainable health insurance; (viii) development of partnership with the private sector; (ix) higher ethical standards and elimination of illegal practices; (x); and (xi) guaranteed access to and rational use of pharmaceuticals. 16 CHAPTER 2: MAIN SECTORAL ISSUES 2.1. Stewardship and Governance 17. Stewardship refers to good principles of health and healthcare governance, a responsibility that is usually assigned to the Ministry of Health.15 Stewardship is considered a core function of healthcare, together with financing, human resource generation and service delivery. Four conceptual issues are important to stewardship: • the specific functions of stewardship, including; o providing strategic direction for policymaking in health and healthcare; o (setting up and enforcing a legal and regulatory framework, as well as mechanisms and tools for the operationalization and implementation of policies; o ensuring a coherent institutional and organizational structure and culture to support the achievement of policy objectives; and o generating intelligence to monitor and evaluate policy implementation. In a truly pluralistic system, the State assumes the role of stewardship by making policies, legislating and regulating transactions among the payers, providers and consumers and collecting information to ensure that each party respects the rules and regulations (i.e., payment compliance, quality of services, etc.). This role in turn requires active involvement of all stakeholders in system governance and management (Figure 2.1). • the contextual factors that enable or hinder the fulfillment of these functions; • the actors and/or stakeholders involved in stewardship; and • the level of governance where responsibilities for specific functions are assumed and executed. Figure 2.1: Institutional and Functional Linkages between Main Stakeholders in Health Care Direct payments Population/ Health services Providers of care Consumers Government: Ins •Policy ur Ta an •Legislation xe ce so •Regulations ts co ge rc ve •Intelligence ud on ra s aim lb trib ge ba uti Cl glo on s of es Fe Third-party payer Source:Modified from Reinhardt U.E. In health care system in transition. OECD, 1991 p.105. 15 The World Health Report 2000 defines stewardship as “the careful and responsible management of the well-being of the population.� 17 18. Pluralism is limited due to predominance of State and Para-statal agencies, with limited participation by providers and population. 16 The role of providers in system governance is very limited. Provider associations as true representatives of all the professionals do not have a formal platform to participate in policy decisions affecting them directly (e.g., human resources policy and planning; salary negotiations; curriculum development; licensing, certification and registration; definition of financial and non-financial incentives; development and enforcement of ethical standards; malpractice issues; and the management of patient grievances). They do engage in negotiations pertaining fee schedules, but the final decision is administrative rather than being consensual.17 19. System governance is segmented due to overlapping functional responsibilities between the MOH and payers. Since the passage of the Law on CMB, the establishment of ANAM and the expansion in the mandate of CNSS to also provide health insurance to blue collar workers in the formal sector, there has been a chevauchement in the roles and functional responsibilities of the payer agencies and the MOH. In theory there is both horizontal (i.e., functional) and vertical (i.e., population groups) segmentation in that the MOH, CNOPS and CNSS (and soon ANAM) are each involved in financing for their own population groups (e.g., the blue collar workers, civil servants, etc) and, to a varying degree, in service provision (Figure 2.2).18 While governance at the central level is fragmented, with MOH and ANAM having overlapping responsibilities in regulating the health care system, the MOH plays a predominant role in the execution of all key functions, i.e., policy making, regulation, financing and service provision despite the existence of separate payer agencies, each with a mandate for a different segment of the population. Three other agencies, in addition to MOH, are also involved in financing, management and regulation—CNOPS, CNSS, and ANAM—each defining entitlements and obligations of their contributors, or more specifically, the benefit packages, premium rates, and pricing, and reimbursement of health and related social services. However, as mentioned above, their power and accountability in matters of financing, resource allocation and purchasing is limited due to lack of full autonomy and independence from the MOH. The ANAM, essentially a regulatory agency, was asked to manage RAMED, thus assuming a managerial function for one segment of the population, the poor, while developing its institutional capacity as an insurer and purchasing agency, albeit under the purview of the MOH through which it is set receive a large part the budget. Yet, services which RAMED will ensure will be provided in facilities owned and managed by the MOH. 20. There is a burgeoning private provider network. The private sector is relatively new, but expanding in a lax regulatory environment with limited, albeit growing opportunities for contractual arrangements with the main payer agencies, especially since the arrival of AMO. There are several private hospitals, often called clinics, with a legal stature defined as “Société civile professionelle� and having limited liability through their owners or shareholders who by law are obliged to be health professionals. Thus direct private investment into the health sector by non physicians is not permitted. On the other hand, there are no tax incentives or other subsidies for those who would consider investing in private service provision. 19 In addition they are not allowed to surcharge beyond the negotiated fee with the insurers. As such there is a tendency to invest in high-tech equipment and specialize in surgical disciplines (e.g, cardiac surgery, lithotripsy) and medical imagery. 16 Actually, labor unions are represented in the management board of ANAM and providers do negociate with payer agencies (CNSS and CNOPS) for setting the fees. However, power sharing is not equitable in ANAM management with Minister of Health having the prerogative in all major decisions. 17 The providers have to accept the administrative decisions of the payer agencies on the fee schedule, but than go on to charge the balance to the patient. 18 Only recently that CNOPS ceased to provide health care services, but they still provide medication to the chronically ill. The CNSS is in the process of tendering its 13 health facilities to the private sector. 19 There are a few exceptions, as in the case of foreign investment from the GCC countries in high-tech modern hospitals where even foreign doctors are allowed to practice. 18 Figure 2.2: Functional Segmentation in Health System Governance Main Functions MOH ANAM (*) CNOPS CNSS Population Providers /Patients Policy/ ++++ ++ + + - + Regulation Financing +++ + ++ ++ +++ - Purchasing/ ++++ + ++ ++ + ++ Payment Service ++++ n/a + ++ - +++ Delivery(**) Organization/ ++++ ++ ++ ++ + - Management Human +++++ - - - - - Resources Development Legend: (+) minimal responsibility to (+++++) exclusive responsibility N.B. responsibility does not equate to actual execution. (*) Including its responsibility for the management of RAMED (**) CNOPS and CNNS are in the process of reducing their involvement in service provision. 21. Centralization hinders effective governance. MOH directly oversees administration and financing of all health agencies and facilities in the public sector. At present, there is limited decision power transferred to sub-national and local authorities for more integrated and multisectoral planning at the local level. As such, the deconcentration of administrative responsibilities to local health authorities and the devolution of managerial responsibilities to regional authorities remain protracted. A technical audit of MOH conducted in 2004 to assess the extent of decentralization concluded that while the centralized structure set in place in 1994 to respond to health challenges has been effective, it has outlived its usefulness and it now impedes system governance. The study concludes that MOH’s structure remains hierarchical and fragmented, hindering therefore integration at the central level and coordination with lower levels of MOH administration. Other observations include: (i) the separation of outpatient and inpatient care service delivery that undermines gate-keeping, continuity of care, hierarchy in access to different levels of care and patient referral; (ii) absence of mechanisms or responsible administrative units to fulfill core functions such as regulating the private sector, standard setting, licensing, contracting, and technical audit; and (iv) lack of separation of financing/purchasing from service delivery. 22. Provider compensation mechanisms do not value productivity, quality of care or performance. Physicians, nurses and other health professionals in the public sector are paid fixed salaries. Although less poorly than many other countries of similar economic level, the amount of payment is more proportional to seniority than productivity or performance. Highly paid and thus coveted senior positions in teaching hospitals are rare. Apart from this elite group, most physicians have very little voice in decisions affecting their career opportunities and compensation levels. Accordingly, those who can generate revenues outside the confines of civil service positions (mostly physicians, but to a lesser extent nurses and midwives), may be tempted to resort to charging informal fees, a practice that undermines the authority and legitimacy of the healthcare system. While better- skilled physicians leave the public sector entirely and practice only in the private sector, a large majority remain on public payroll, mainly for job security, pension and other benefits, but “moonlighting� without paying taxes on the additional income. 19 23. The population has very little involvement in system governance or policymaking. Apart from a few pilot initiatives to empower communities in community-based financing schemes, no mechanism exists for more formal public participation in system governance in general, or that of health facilities in particular. 20 Accordingly, their involvement is reduced to paying taxes and premiums for social protection services, as well as formal and informal out-of-pocket payments to healthcare providers (Box 3). Box 3: Informal Payments in the Health Sector “Mon mari s’est blessé au doigt dans son travail, il a été transporté à l’hôpital. Ce n’est que lorsqu’il a donné 300 Dhs qu’ils lui ont fait des radios et encore 200 Dhs pour être recousu. Il s’est fait soigner dans un hôpital public et a du débourser 500 Dhs » (an interviewee in Casablanca) According to a survey conducted in 2002, 88 percent of households believe that the public health care system is a major problem, especially in the northern part of the country where the rate reaches 97 percent. Forty nine percent of the heads of households think that corruption in the health sector is very common amongst the health workers, especially the nurses and the administrative staff, and another 31 percent think that it is common. These rates are somewhat higher amongst the owners of small enterprises in the informal sector who commonly lack health insurance. The health sector is ranked third on the list of most corrupt sectors, after the transport sector and the “moqqadems et chioukhs�, again at a higher frequency by the population in northern provinces. Unlike in other sectors, though, about 31 percent of heads of households believe that it is acceptable to make an informal payment to cover hospitals costs of a family member, potentially a constraint to attempts to contain informal payments in the health sector. Translated from: Transparency Maroc: La corruption au Maroc; Synthèse des résultats des enquêtes d’intégrité. L’Université de Transparence, 2002. 2.2. Health Financing and Expenditures 24. Morocco spends less on health care compared with countries of similar socio-economic development. Despite recent increases in total health expenditures21, Morocco spends less on health care, about 5.1 percent of its GDP in 2004, or US$ 82 per capita (US$ 234 international dollars) (Figures 2.3 and 2.4).22 While one could argue that once controlled for the Purchasing Power Parity (PPP), total health expenditures may be close to what would be expected for its level of socio- economic development (Figure 2.5 and 2.6), one needs to keep in mind that about 1/3 of expenditures are for drugs and other supplies which are priced internationally. 20 During the last five years a number of community-based insurance schemes, the “les mutuelles communautaires� have been set up with assistance from WHO, UNFPA and UNICEF, covering 22 communes in seven Northern provinces. They basically cover essential drugs and medical evacuation. In general, the participation rates are not high and often declines after the first year. is 21 In early 1990s Total Health expenditures in Morocco accounted for 3.4 percent of GDP versus 3.7 percent in Egypt, 4.8 percent in Iran, 5.9 percent in Tunisia and 6.5 percent in Jordan. 22 Compared with 6.1 percent in Egypt, or $66 per capita ($258 PPP); 9.8 percent in Jordan, or $200 per capita ($502 PPP); and 6.2 percent in Tunisia, or $175 per capita ($502 PPP). Please see Annex 4 for a global comparison of health expenditures. 20 Figure 2.3: Regional Comparison of Total Figure 2.4: Regional Comparison of Per Capita Health Expenditures Health Expenditures, 2004 as Percentage of GDP, 2004 (Current US$) Lebanon 11.6 Yemen 30 Jordan 9.8 Djibouti 53 Iran 6.6 Egypt 64 Djibouti 6.3 Morocco 82 Algeria 94 Egypt 5.9 Tunisia 126 Tunisia 5.6 Iran 158 Morocco 5.1 Jordan 200 Yemen 5 Oman 295 Bahrain 4 Saudi Arabia 348 Saudi Arabia 3.3 Bahrain 620 Oman 3 Kuwait 633 United Arab Emirates 2.9 Lebanon 670 Kuwait 2.8 United Arab Emirates 711 Qatar 2.4 Qatar 992 0 2 4 6 8 10 12 14 0 200 400 600 800 1000 1200 Source: World Development Indicators 2007, Source: World Development Indicators 2007, World Health Report 2006 World Health Report 2006 Figure 2.5: Global Trend in Total Health Figure 2.6: Global Trend in Total Health Expenditures, 2004 Expenditures, 2004 (per capita GDP in PPP) 16 Lebanon 16 Total Health Expenditure as % of GDP (%) y = 0.0001x + 5.1371 Total Health Expenditure as % of GDP (%) 14 14 y = 7E-05x + 5.7609 R2 = 0.267 R2 = 0.1409 12 12 Jordan Morocco 10 10 Iran 8 Djibouti Morocco 8 Iran 6 6 Tunisia 4 4 Yemen Algeria 2 Syria 2 0 0 100 1,000 10,000 100,000 100 1,000 10,000 100,000 Per capita GDP,2004 (Current US$) Per capita GDP PPP,2004 (Current International $) Source: World Development Indicators 2007, World Health Source: World Development Indicators 2007, World Health Report 2006 Report 2006 25. Public expenditures on health are low relative to total health expenditures. In 2005, public expenditures on health accounted for 34.3 percent of total health expenditures, or 1.75 percent of the GDP, both in terms of current and after adjustment by PPP. This rate is quite low by international standards (Figure 2.7 and 2.8), considering the fact that in 2002, government revenues as a share of the GDP was 26.8 percent, higher than that in Jordan (24.7 percent), Iran (26.5 percent), Egypt (19.5 percent) and Lebanon (19.1 percent) and slightly lower than that in Tunisia (29.9 percent).23 23 Source: World Development Indicators 2007. N.B: Revenue figures exclude the amount of grants. 21 Figure 2.7: Global Trend in Government Figure 2.8: Global Trend in Government Expenditures on Health, 2004 Expenditures on Health, 2004 (per capita GDP in PPP) 9 9 8 8 y = 0.0001x + 2.3668 y = 0.6468x 0.2037 Health Expenditure as % of GDP (%) Health Expenditure as % of GDP (%) R2 = 0.4441 7 R2 = 0.2604 7 6 6 Morocco Morocco Government Government 5 5 4 4 3 3 2 2 1 1 0 0 100 1,000 10,000 100,000 100 1,000 10,000 100,000 Per capita GDP, 2004 (Curremt US$) Per capita GDP PPP,2004 (Current International $) Source: World Development Indicators 2007, World Health Source: World Development Indicators 2007, World Health Report 2006 Report 2006 26. Out-of-pocket expenditures account for a larger share of total health expenditures. About 65.7 percent of total health expenditures are private. Direct out-of-pocket expenditures accounting for 76 percent of total private expenditure, or 49.9 percent of total health expenditures (Figure 2.9), quite high especially relative to Morocco’s fiscal capacity, in relation to what government spends as a percentage of the GDP (Figure 2.10), indicating less-than expected public financing of health care. Private health expenditures account for 65.7 percent of total health expenditures, predominantly out-of-pocket payments that are 76 percent of total private health expenditures (see Annex 5 for details). Figure 2.9: Health Financing in Morocco 1998-2001 59,37% 60% 57,67% 50% 40% 1997-98 2001 30,40% 30% 26,16% 20% 10% 4,83% 4,73% 4,86% 3,74% 2,50% 1,25% 1,49% 1,02% 1,65% 0,69% 0% Private Communes State-owned Int’l Dev Others State Households enterprises enterprises Assistance Source: MOH, National Health Accounts, 2001. 22 Figure 2.10: Global Trend Analysis of Out- Figure 2.11: Out-of-Pocket Health Expenditures of-Pocket Health Expenditures, 2004 and Fiscal Capacity, 2004 80 80 y = -9.1643Ln(x) + 114.23 Out-of-Pocket as % of Total Health Expenditure Out-of-Pocket as % of Total Health Expenditure R 2 = 0.2821 70 70 Morocco 60 60 Morocco 50 50 y = -26.876Ln(x) + 109.04 40 40 R2 = 0.3191 30 30 20 20 10 10 0 0 100 1,000 10,000 100,000 0 10 20 30 40 50 60 Per capita GDP,2004 (Current International $) Government Spending as % of GDP, 2004 Source: World Development Indicators 2007, World Source: World Development Indicators 2007, World Health Health Report 2007 Report 2007 27. Morocco has a two-tiered health care system. One tier is for the formally employed, living in large cities and enjoying full access to a generous package of healthcare services paid for or subsidized by the state24 and predominantly provided by the private sector,25 and the other is for the rest of the population working in informal sectors or living in rural areas where geographic and financial access to basic services is limited to existing public health facilities where the quality of care is lower (Figure 2.12). Figure 2.12: Gradient in the choice and use of health service by expenditure quintiles Panel A: by Health Facilities Panel B: by Health Providers 95 70.0 85 in % of total population in each quintile in % of population in each quintile 60.0 75 65 50.0 55 40.0 45 30.0 35 20.0 25 15 10.0 5 0.0 1 2 3 4 5 -5 1 2 3 4 5 Free Clinic 29.3 20.9 18.5 13.4 6.5 Doctor/Dentis t 79.7 88.3 90.6 87.8 91.0 Health Center 13.4 11.3 6.6 5.4 3.5 Pharm acist 3.6 4.6 5.1 8.2 6.9 Public Hospital 19.3 21.8 19.5 17.7 11.9 Nurse/Midwife 11.8 4.8 3.0 1.7 0.3 Private Doctor/Clinic 34.1 40.9 50.5 56.1 71.2 Traditional/spiritual therapist 2.6 1.6 0.6 0.9 0.9 Pharmacy 2.1 2.9 3.0 3.7 1.8 Others 2.2 0.8 0.6 1.3 1.0 Others 1.8 2.1 1.9 3.8 5.1 Source: National Survey on Household Consumption and expenditures (ENCDM), 2001 28. The second group’s access to quality care comes at the expense of large out-of-pocket payments for those who can afford them. Private health expenditures are about 67 percent of total health expenditures, three-fourths of which is out of pocket, putting considerable strain on household budgets, especially for the poor and the rural whose means of survival are much more meager and who cannot afford additional expenses for essential health care (Figure 2.13). 24 A benefit incidence analysis using 1998/89 LSMS data indicates that the share of state subsidies on health care for the richest quintile was 25 percent vs. 13 percent for the poorest, reaching 32 percent for outpatient care and 24 percent for inpatient care for the richest, compared with 9 percent for both, respectively. Overall 87 percent of the subsidies went to the non-poor and 64 percent went to urban residents. 25 About 90 percent of the services consumed by CNOPS beneficiaries are provided by the private sector. Only about 6 percent of the funds reimbursed by CNOPS are made to public providers, although this may increase as CNOPS management plans to increase the public sector share as a result of higher private provider tariffs. 23 Figure 2.13: Private Health Expenditures in Morocco Panel A: Poor vs. Non-poor Panel B: Urban vs. Rural Mean percapita health expenditures Mean percapita health expenditures 10.0 10.0 in % o f t o t a l b u d g e t in % o f to ta l b u d g e t 8.0 8.0 6.0 6.0 4.0 4.0 2.0 2.0 0.0 0.0 Poor Non-poor Overall Urban Rural Overall 1998 4.3 7.0 6.9 1998 7.6 5.0 6.9 2001 5.1 7.9 7.6 2001 8.3 5.6 7.6 Source: Calculated based on data from HECS 1998 and ENCDM 2001 household surveys 29. Private health expenditures constitute a significant proportion of the poverty gap. A more meaningful demonstration of the impoverishing effect of private health expenditures is reflected in the proportion of the poverty gap that would be reduced if the poor did not pay for healthcare. In other words, if it takes 100 dollars per poor person per year to eradicate poverty in a country, i.e., if perfectly targeted and distributed, this amount should suffice to bring everyone below the poverty line to just above the poverty line, per capita health expenditures of the poor per year amount to about 14 dollars. This gives us a good way to benchmark health spending against the depth of poverty as it magnitude is a significant percentage of the poverty gap. In other words, about one-seventh of the total poverty gap can be bridged if poor were to be exempted from their health care expenditures, and was unchanged during 1998-2001 (Figure 2.14). Figure 2.14: Per Capita Health Expenditures of the Poor (Percent of Poverty Gap) 18.0 16.0 as % of total poverty gap 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 1998 2001 Source: Calculated based on data from HECS 1998 and ENCDM 2001 household surveys 30. While the government has extended health insurance coverage, it still covers the formal sector. At present, about 32 percent of the population is covered, compared with 16.3 percent before AMO was introduced (then 3.6 percent of the rural population and 21.8 percent of the urban population), but most of the expansion has been in the formal sector.26 This was expected, as Morocco is reinforcing the institutions of social protection, including health insurance, for the formally 26 While expansion of coverage under CNSS and CNOPS moves ahead, progress with RAMED is at a standstill. CNSS aims to expand its coverage from about 1.8 million to full coverage of 4.5 million workers by the end of 2008 with additional coverage of about 1.35 million a year. Since the passage of AMO, there has been a steady increase in the number of civil servants, retirees, and their dependents covered by CNOPS, from about 2.5 million to 3.2 million. 24 employed, to reach several social and economic policy objectives. Recognizing the limited and inequitable coverage for the poor, the government has, in addition to expanding AMO to all formally employed, retired, and their families, introduced RAMED to cover the poorest. By 2010, the government expects that RAMED will cover about 8 million poor and vulnerable Moroccans, or 21 percent of the population, and AMI-INAYA, 27 the new scheme for the self-employed, will cover another 6 percent, increasing total coverage from 16.3 to 61 percent of the population. However, with the low institutional capacity and fiscal constraints on one hand and the current emphasis on the formal sector through AMO is likely to limit progress in introducing and operationalizing RAMED and accentuate structural inequalities rather than diminishing them.28 The emphasis should be on what can be achieved in the short run with the existing institutional framework, while institutional build-up and financing for RAMED are delayed. 31. Private health insurance is burgeoning. Health insurance coverage in the private sector which varies considerably in scope is more generous than what is offered in the public sector. For instance, the Moroccan Inter-professional Mutual Fund (IMIM) offers coverage to the employees of 256 companies in the oil and banking sectors. Premiums are equally paid for by the employees and employers and the reimbursement rates are higher. As for purely private insurance, rather than a mutuelle, its scope is very limited, covering a few private companies where employees and employers co-share premium costs equally. Again, their reimbursement rates are better. However, they typically run deficits, offset by profits generated from other insurance products.29 2.3 Resource Allocation and Purchasing 32. Low Public expenditures on health exacerbate inefficiencies in resource allocation and use, leading to high private expenditures. The share of public expenditures on health is 34.3 percent, lowest among the MENA countries and at par with low-income countries.30 Government expenditures on health was about 5.5 percent of total government expenditures, and the MOH budget was 5.4 percent of the government budget in 2004, low compared with similar countries. And yet, most of the public funds benefit the better off. 31 In 2004, only 7.6 percent of total public expenditures on health came from premiums collected by CNOPS and CNSS beneficiaries, which then covered 16.2 percent of the population, reflecting a large state subsidy of the formally insured, especially considering the volume and mix of services they receive, albeit with some co-payments. The rest of the population was not covered, except for indigents who are certified by the Ministry of Interior for free access to public health care facilities.32 This scheme, however, is prone to abuse, for it is often the richest who receive free access, again indicating the structural inequalities in care. 33. Public funds go where the resources are, not where the needs are. A 2004 report by RAMED indicated that 67 percent of the free services provided in hospitals benefited the richest quintile and only 5 percent benefited the poorest. The Bank’s own benefit incidence analysis of the health sector, carried out based on 1998 data shows that public subsidies benefit the wealthiest and the urban the most (Figures 2.15, 2.16 and 2.17). 27 INAYA is an Arabic word meaning “taking care or you� (prendre soins de vous). This new scheme will offer three packages of services, be managed through private insurance companies or a mutuelle, and will eventually cover 10 to 13 million people. At present, only the basic package is offered, aimed at people with income just above the poverty line. 28 The government will find it difficult to pay for the increasingly costly demands of the AMO beneficiaries and at the same time introduce RAMED, which may cost up to 2.5 percent of GDP, all at a time when the pension system has a large deficit and unfunded liabilities. See David A. Robalino (2007) for a discussion of the demand for fiscal support to cover the deficit of mandatory pension schemes. 29 Waters et al claim that their income amounts to about 70% of their expenditures. 30 In 2003, the average GDP per capita for low-income countries was US$481 whereas in Morocco it was US$1,349 (adjusted by exchange rates). 31 Resource allocation is already inefficient as the beneficiaries in the formal sector who tend to live in urban areas, consume more expensive hospital-based care, and have easy access to pharmaceuticals. 32 Certification is open to corruption, and it is rumored to cost 140 DH to buy one (Rapport de revue/d’identification de l’appui de la Commission européenne à la consolidation de la couverture médicale de base au Maroc, February 2007). 25 Figure 2.15: Distribution of Public Subsidy on Health by Type of Service and Quintile 35% 30% 25% Primary 20% Outpatient 15% Inpatient All health 10% 5% 0% Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 Source: LSMS 1998/99, Ministry of Health (2000), and WB Staff Calculations Figure 2.16: Distribution of Public Subsidy on Health by Type of Service and Poor/Non-Poor 100% 90% 80% 70% Primary 60% Outpatient 50% Inpatient 40% All health 30% 20% 10% 0% Poor Non-poor Source: LSMS 1998/99, Ministry of Health (2000), and WB Staff Calculations Figure 2.17: Distribution of Public Subsidy on Health by Type of Service and Urban/Rural 80% 70% 60% 50% Urban 40% Rural 30% 20% 10% 0% Rural Primary Urban Outpatient Inpatient All Health Source: LSMS 1998/99, Ministry of Health (2000), and WB Staff Calculations 34. One consequence of poor resource allocation is that CHU’s receive the lion share of public outlays. Limited public funds are poorly allocated across levels of care, with 40 percent going to centres hospitalo-universitaires (CHUs), 27 percent to SEGMA hospitals, and only 22 percent going to ESSBs. This would have been understandable if the CHU’s had truly a national vocation and their services were accessible to all including those referred from the ESSBs. While more detailed analyses are needed to document to what extent admissions and outpatient visits in CHUs originate from the cities where they are located, the existing evidence on the share of budgetary allocations to CHUs points out towards a mismatch of resources in favor of the two CHUs in Rabat and Casablanca simply because they are better endowed in terms of modern equipment and competent health professionals (Figure 2.18). 26 Figure 2.18: Budgetary Allocations for Public Hospitals, 2005 35 000 000 $ 30 000 000 $ SEGMA et Soutien CHU Pharmacie centrale (SEGMA et Soutien) 25 000 000 $ 20 000 000 $ 15 000 000 $ 10 000 000 $ 5 000 000 $ - $ uz en e er ra a a ha at r a n Za ou a t e ao ss ra le ar ui l nc la ua un bd an al ig go ila -D em jd iH lH zi nt la r- rd to ao -A lm ou -A af La ab rie ou en Te E ua S -T sa ou -T B O a as m - s B -O la - as -B al -E r- - ift ab em a ad C s - kk ne m M ns ge ne da ah ia nd T im s ou -Z ou ei Te an ek Fe - ou ar dd oc lm ra ss D ay M T ha hr é G - lH E ou ue La al ch -C C d S S -A G ue ke - rb O ra at a ha az ab ar G M T R Source: MOH, 2005 35. Absence of a “carte sanitaire� exacerbates inefficiencies. A bias in resource allocation towards hospital-based care resulting from practices based on inputs (beds, health professionals) undermines the quality of care and makes the system unlikely to respond to preventive and curative healthcare needs.33,34 Other inefficiencies include: • The size of the wage bill. In a country with large human resource deficits, with only one doctor for every 2,000 people,35 salaries and wages are 75 percent of public health expenditures, high for middle income countries. • Mismatch between public supply and private demand. The private sector accounts for 62 percent of all expenditures even though 80 percent of the hospital beds are in the public sector. • Mismatch between a relatively large supply of inpatient care and demand for outpatient care. Hospitals account for 31 percent of total health expenditures, outpatient care for 33 percent, and drugs and consumables for 36 percent, indicating that most expenses are for outpatient visits to private providers. • Low level of budget execution, at about 80 percent for materials and consumables and 50 percent for investment. 36. Money does not follow the patient, let alone the population, but is allocated based on what is already there and historical expenditure patterns. While there have been efforts to improve allocational efficiency, such as SEGMA, or autonomous management of health facilities (chartes communales) to make local authorities responsible for health promotion, la contractualisation in hospitals, and la loi sur la régionalisation for hospital investment, these have not been fully implemented as a result of lack of political will and limited central and local capacity. There has been no pooling of resources and purchasing, or careful design of financing, benefits and eligibility conditions, delivery and payment systems, or management/governance structures of health facilities to provide incentives for efficiency, improved quality, increased provider and citizen satisfaction, and reduced informal payments. As a result, the average bed occupancy rate in public hospitals is quite low (Figure 2.19). 33 At present, 47 percent of MOH’s budget is spent on inpatient care (15 percent on CHUs and 32 percent on other public hospitals), and only 38 percent on primary care (preventive and ambulatory care). Only 36 percent of births in rural areas are attended by a skilled health professional compared with 83.1 percent in urban areas. Immunization coverage is less than 60 percent for the poorest quintile and 95 percent for the richest. 34 See the variation in Caesarian rates as a proxy for quality of care, accounting for 58 per 1,000 of all births in Casablanca, but only 10 in Tadia Azilal compared with a national average of 27. 35 Compared with 0.7 physicians in Tunisia, 0.85 in Algeria, 2.05 in Jordan and 2.12 in Egypt per 1,000 inhabitants. 27 Figure 2.19: Comparison of Bed Occupancy Rates (BORs) in MENA 1995-2005 90 83 79 78 80 73 67 70 62 60 58 58 57 60 56 52 50 50 40 30 25 20 10 0 S yria Tunisia Ba hra in WBG Ir a n J orda n Kuwa it Oma n Ir a q Moroc c o Le ba non UAE Alge ria Egypt Source: World Development Indicators 2005 and World Bank Staff calculations 28 CHAPTER 3: AN AGENDA FOR HEALTH SECTOR REFORM 3.1 Reducing inequalities in health and access to healthcare 37. Investment in ESSBs and human resources development is essential. Inequalities in health and access to health care are complex, reflecting both financial constraints on the demand side and geographic and organizational imbalances resulting from the lack of physical and human resources in ESSBs and effective targeted programs on the supply side (Figure 3.1). 36 To reduce these inequalities, the government must adopt a two-pronged strategy. Introducing RAMED will not be sufficient unless there is sufficient investment in ESSBs to improve access to quality care. This requires understanding the risk factors and illnesses affecting the poor and the rural, and developing and adopting a carte sanitaire as a basis for investment in socio-sanitary regions. In the medium term, the private sector will not invest and establish in areas where financial returns are not enticing. Public investment is needed to establish gate keeping and a hierarchy of levels of care (population-based disease prevention and health promotion, primary health care, and basic secondary health care services) to be provided in public health polyclinics and provincial hospitals. Preparing and adopting the carte sanitaire should be carried out in tandem with preparing and adopting a longer-term human resources development policy and strategy for improved access and quality. Figure 3.1: Human and Physical Resources in Morocco, 2005 Physicians 2.0 1.5 Health Manage ment and support Numbe r of be ds worke rs 1.0 0.5 0.0 Midwi ve s Nurses Pharmacists De ntists Morocco Reference country average (*) Source: World Health Statistics, 2007 38. Additional public financing is needed to expand population coverage to the poor. At present, public financing of health care in Morocco is inadequate (Figure 3.2). Cognizant of its limited role in financing, the State intends to finance RAMED properly, albeit with some with some cost sharing by beneficiaries and communities. According to ANAM, the additional costs for 2007 amount to DH 2.6 billion to cover the health care needs of a population of about 8.5 million through access to a basic benefit package (BBP) of outpatient visits, diagnostics (laboratory and imaging), inpatient care, and case management of chronic diseases, including medication. These estimates cover two groups of beneficiaries, the absolute poor (4.0 million) and the vulnerable (4.5 million) and two types of services, inpatient care (DH 2.9 billion) and outpatient care (DH 1.7 billion). The source of financing would be 36 MOH estimates there is a shortage of 7,000 physicians and 9,000 nurses in the public sector. With production rates of 800 physicians and 1,500 nurses a year, average duration of nine years to train a physician, and the attrition expected in the next ten years, the health workforce deficit will not be covered in next 10-15 years unless the government defines a new human resource policy and strategy and invests in producing health care workers of all levels. 29 three-fold: (i) DH 562 million to be paid for by beneficiaries through an annual fee of DH 100 per capita up to a maximum of DH 500 per household for an estimated total of DH 421 million and a user fee of DH 10 up to a maximum of DH 300 for outpatient visits, lab tests, and imaging, for an estimated sum of DH 141 million; (ii) contributions by local communities to cover annual fees for pauvres absolus, estimated at DH 587 million; and (iii) state contribution of DH 1,469 million, including DH 1,048 million, or 38 percent of the MOH budget, excluding salaries, subsidies to the CHUs (DH 564 million), SEGMAs (DH 374 million), régie hospitals (DH 70 million), and for insulin procurement (DH 40 million). These estimates exclude wages and benefits, estimated at DH 800 million, and 10 percent of the total as administrative costs. According to ANAM, an annual increase of about 1.7 to 3.7 percent of total expenditure is forecast for increases in service use, aging and sectoral price increases, despite the expected decrease in poverty levels, that is, in the number of RAMED beneficiaries. Figure 3.2: Health Financing in Morocco, 2005 Total expenditure for health as % of GDP 12.0 10.0 8.0 Per capita public exp on health at Gov exp on health as % of total exp 6.0 PPP on health 4.0 2.0 0.0 Per capita total exp on health at Private exp on health as % of total PPP expenditure on health Gen gov exp on health as % of total gov exp Reference country average (*) Morocco Source: World Health Statistics, 2007 39. Future growth projections of GDP and of government revenues may open the needed fiscal space for the expansion of AMO and RAMED. During the next 4-5 years, the real annual GDP growth is expected to remain above 5 percent. Government revenues are forecasted to reach 26 percent of the GDP and the public debt ratio to GDP is expected to decrease from 69.9 percent in 2005 to 52.5 percent in 2010 (Table 3.1). Table 3.1: Macroeconomic Projections, Morocco, 2006-2011 2006 2007 2008 2009 2010 2011 GDP (billion USD) 63.3 70.0 73.0 76.1 78.4 83.0 Real GDP growth (%) 9.3 3.8 5.1 5.4 4.8 5.3 Exchange rate: US$ (average) 8.8 8.4 8.6 8.9 9.2 9.3 General government expenditure (% of GDP) 26.6 27 27.1 27.1 27.3 27.5 General government revenue (% of GDP) 24.8 25 25.5 25.5 25.9 26.3 General government budget balance (% of GDP) -1.8 -2.1 -1.6 -1.6 -1.4 -1.1 General government debt (% of GDP) 67.0 62.9 59.4 55.7 52.5 49.1 Government consumption (annual growth %) 5.9 4.2 5.4 5.0 4.5 4.4 Source: The Economist Intelligence Unit, Morocco Country Forecast 2007, June 2007 Longer term growth projections are equally favorable, forecasting an average annual GDP growth of 4.6 percent between 2007 and 2030, or 3.3 percent per capita per year based on a labor productivity 30 growth of 3 percent per annum. Two actuarial studies estimated that RAMED would cover about 8.5 million Moroccans at a total cost of about DH 4.6 billion. Government would only have to pay for about DH 2.6 billion. Using the latter figure which equates to 0.45 percent of the GDP in 2007, or 1.6 percent of the total government expenditures, there should be sufficient fiscal space in the government budget to cover for the additional fiscal burden of expanding health insurance to 8.5 million RAMED beneficiaries.37, 38 40. ANAM as the implementing agency for RAMED, should become an active purchaser. On the demand side, introducing RAMED could catalyze the development of rural health services delivery, if RAMED funds were allowed to follow the patient. This entails additional financing, not only to provide the services in the benefit package, but also an investment and maintenance allowance to ensure expansion and sustainability of the ESSBs. ANAM could act as an independent insurance agency, with sufficient autonomy to purchase services from the ESSBs rather than becoming, eventually, a passive payer, in addition to being as it is at present, an administrator. These contractual agreements with each ESSB should be made under the overall umbrella of budget-programmes with regional health departments which are drawn on the basis of epidemiologic and demographic profiles of beneficiaries in each region. Such an arrangement will, on one hand, delegate accountability for allocational efficiency to regional departments while developing their own institutional capacity to ensure that they get good value for its money, and on the other, will preserve the advantages of direct contracting of ESSBs by ANAM for better technical efficiency. This would require developing an information system to track the amount, volume, and mix of service use of beneficiaries at different levels of care. ANAM would also need unambiguous policies and procedures for referring patients to higher levels of public and private care, possibly outside the regional catchment area. 41. ANAM should become a truly independent regulatory agency. ANAM, the agency designated to run RAMED, and several commissions established under the Prime Minister are working to define eligibility criteria, the basic benefit package, administrative rules and regulations for certifying the eligible population, and the information management system. ANAM should complete the regulatory framework, guidelines for eligibility, coverage and piloting RAMED. ANAM is preparing a circular that defines the procedures for issuing certificates of indigence, registering beneficiaries, and the roles and responsibilities of the Ministry of Interior, ANAM, service providers, and patients, and the financial, human and informational resource needs as a first step to piloting the scheme at the provincial level. 42. AMI-Inaya should be prioritized because of its labor market implications. In Morocco youth unemployment rates are particularly high among the educated. This is so, because educated women often may choose to wait for a job in the public sector which admittedly offer better wages and benefits such as maternity leave. While the wage differentials for men between the public and private sector is less, though still substantial, they also prefer the public sector because of job security and other advantages such as health insurance. However, in Morocco, public sector employment is less then 10 percent of total employment and it is more likely to gradually decrease as a result of the on- 37 In 2007, Morocco is expected to spend about US$3.6 billion in total, only 34.3 percent of which, or US$1.23 billion, is public. The additional costs of DH 2.6 billion (US$ 310 million at 2007 exchange rate) implies a 25 percent increase in government expenditures on health, or 11.2 percent increase in total health expenditures if all 8.5 million RAMED beneficiaries were covered at once. Obviously this is a rough estimate of the additional fiscal burden based on a number of assumptions made in the actuarial studies. More detailed analyses would need to be carried out once there is an agreement on the entitlements and obligations of RAMED beneficiaries in terms of the benefit package, user fees, co-payments etc., which then need to be imputed over time based on other assumptions such as increase in service use, changes in service mix, and general and sectoral inflations. In any case, given serious constraints on the supply side, an out-of-control in cost increases would be unlikely. 38 On the other hand, RAMED is first and foremost a social assistance program, rather than a health insurance scheme, and as such its fiscal and financial probity should be assessed together with the other social protection schemes that impose a heavy burden on government coffers. For instance, the indebtedness of the pension plans, the Caisse marocaine de retraite (CMR) and the CNSS, amounts to 77 percent and 64 percent of GDP, respectively. 31 going public administration reform. 39 Given the 30 percent unemployment rate among the highly educated and close to 25 percent among the secondary level graduates, a proactive labor policy should identify mechanisms to expand social insurance coverage to the self employed and casual and seasonal workers in the agricultural sector through AMI-Inaya together a fair cost-sharing mechanism to minimize the amount of public transfers (e.g., matching contributions).40 43. A pilot could provide valuable experience. Finding the right balance between coverage in terms of publicly financed volume and mix of services and spread in terms of eligibility (full, partial) will be a challenge. A pilot experiment will be needed in one of two newly established regions or in a poor region where there is high degree of political commitment and effective leadership,41 with a view to reducing inequities while safeguarding overall efficiency and fiscal sustainability with constant fine-tuning on the basis of feedback from a rigorous ongoing evaluation. Such a pilot would also allow ANAM to acquire pertinent experience, albeit limited to RAMED at the onset, to test and showcase its institutional capacity and competence in managing an insurance scheme which could, over a much longer period, prove useful in the case of an eventual virtual harmonization and subsequent real consolidation of the entitlements and obligations of all insurance schemes under a single payer. 3.2 Improving allocational and technical efficiency in health care 44. Expanding health insurance coverage is the main policy issue which cuts across all other reform initiatives in the health sector. While the legal basis for expanded population coverage exists, several reforms should be carried out before a road map and a time frame are issued improved allocation efficiency. These include, first and foremost, the preparation and adoption of supply side micromanagement tools such as the carte sanitaire and a human resources development strategy to train the health workforce based on an assessment of healthcare needs. Thereafter, the following actions will be needed: (i) adopting a formula for resource allocation based, on regional epidemiology and demography; (ii) switching from input-based payment to providers to output-based, performance, and results driven modes of payment; (iii) designing and enforcing an appropriate algorithm and financial incentives for gate keeping and patient referral across levels of care; (iv) allocating sufficient financial and human resources to high priority national health programs; and (v) introducing a generic drug policy (setting prices and reimbursement rates, allowing substitution by pharmacists), standard treatment protocols, and guidelines for rational drug use. Annexes 6 and 7 provide a summary of advantages and disadvantages of examples of resource allocation and hospital payment mechanisms, respectively, used in OECD countries. 45. “Contractualisation� is a step in the right direction. A good example is the ongoing piloting of contracting out between the MOH, through the Department of Planning and Human Resources and the regional health departments, and the SEGMA hospitals in the regions. The contractualisation involves three phases: (i) developing a strategic framework as the basis for a “budget programme�; (ii) allocating and executing an annual budget on the basis of a contract; and (iii) ex-post performance evaluation. While the introduction of the contractualisation is a major development, its effectiveness depends on separating purchasing and provision functions and providers (such as SEGMA hospitals) assuming some financial and reputational risk in case of lower- than-expected performance in the form of annulment of the contract or other measures with financial and non-financial implications. Involving local authorities in establishing the strategic framework and defining performance criteria and indicators is a step in the right direction towards pluralism. 39 Actually, Morocco has a lower youth and adult unemployment rates than most MENA countries, slightly over 15 percent in the 15-24 age group and about 10 percent in the 25-64 age group. However, this is probably so because the uneducated in Morocco who live in rural areas has lower unemployment rates than the highly educated living in urban areas. Please see the recent World Bank report “Youth – An Undervalued Asset: Towards a new Agenda in the Middle East and North Africa�, Draft version, May 2007 for more details. 40 Such programs need to be developed without further fragmentation of the social insurance system while ensuring fiscal sustainability and an efficient and equitable allocation of subsidies. Please see the recently issued Bank report on “Skills Development and Social Protection within an Integrated Strategy for Employment Creation�, Draft version, May 2007. 41 Such as Meknes-Tafilalet or Fes-Boulman, two regions with the highest poverty. 32 However, it is difficult to foresee, so long as MOH remains—directly or indirectly through the regional health departments—both purchaser and provider, how the “contractualisation� could become fully functional and effective. 46. “Virtual� integration of payers and harmonization of the basic benefit package are first steps toward a universal health coverage. Once RAMED and AMI-Inaya become fully operational, there will be at least five large insurance schemes, a number of smaller mutuelles and a few private insurance companies.42 At present the premium rates, the benefit packages and the reimbursement rates are quite different across the schemes which not only raise an equity issue, but also has implications for labor market and mobility (Box 4). Their harmonization will reduce segmentation in the sector, improve equity and efficient allocation of resources and simplify administration not only for the insurance agencies and mutuelles, but equally importantly for the providers. It will also pave the way first for a “virtual� integration all operating under the same rules, and eventually, institutional integration under ANAM’s regulatory umbrella. Box 4: Variations in Premium Rates, Eligibility Criteria and Benefit Packages in Morocco There are important variations across various public and private insurance schemes. In the public sector (CNOPS), the premium rate is 5 percent of the total wage, paid equally by the civil servant and the State as employer. The minimum and maximum monthly payments are 70 DH and 400 DH, respectively. The benefit package is quite comprehensive with seven categories of services including, all outpatient and inpatient services, drugs and prostheses and dental care. CNOPS reimburses between 70 and 90 percent of the costs, depending upon the category, the balance being either paid for the patient or his/her own sickness fund (“mutuelle�). In the private sector (CNSS) the premium rate is 4 percent, again equally paid by the employee and the employer. However, the benefit package is not as comprehensive, with age limits for some services and the reimbursement rate is 70 percent, except for ADLs and ACCs. AMI-Inaya offers three options each with its own premium rate and package of services, the premium rates varying between DH 45 to 86 for adults and 36 to 69 for children, depending upon the package. Package 1 gives access only to the public facilities, Package 2 to both public and private with a package identical to that offered by CNSS and Package 3 to all outpatient and inpatient care. The user fee is set at 10% of the prices in the fee schedule with a minimum of DH 10 and a maximum of DH 300 per episode of care. In the case of RAMED, there will not be any premiums for obvious reason, but the beneficiaries will have to pay an annual fee of DH 100 for each member of the household, up to a maximum of DH 500. However, the local communities will pay for the “pauvres absolus� whereas the “vulnerables� will have to pay themselves. Finally, they are expected to pay a 10 percent with a minimum of DH 10 and a maximum of DH 300 per episode of care. 47. Several issues are outstanding. A list of reimbursable drugs has been developed for AMO, and a new law on pharmaceuticals has recently been enacted. However, there still are several outstanding issues, namely: (i) reforming centralized drug procurement; (ii) setting prices for generic drugs; (iii) pharmacist rights and obligations regarding substitution of branded drugs with generic drugs; (iv) use of prices at country of origin for reference pricing; and (v) absence of an integrated information system for recording and invoicing prescriptions for the affectations de longue durée (ALD) and “Affections longues et coteuses� (ALC), two categories of disease for which patients have free access to expensive drugs (insulin, cancer drugs).43 48. Implementation depends on political will and consensus building. Several of these policy measures have been studied or piloted through Bank-, EU- or other donor-financed projects. Their scaling-up and successful implementation will depend on political will and on compliance from regional authorities and providers. This will require an open and transparent consensus building 42 CNOPS, CNSS, RAMED, AMI-Inaya and the Moroccan Inter-professional Mutual Fund are the largest schemes. In addition, there are independent mutuelles, e.g., the Military, Royal Air Maroc and so on. 43 CNOPS prefers buying expensive drugs in bulk to avoid wholesale and retail surcharges that distort the pharmaceutical market. The existing price setting mechanism, which relies on market prices in the country of origin with a mark-up for importation and profit, often results in prices a few times higher. Augmentin, a frequently used antibiotic, is 2.5 times more expensive in Morocco than in France. There are no positive or negative lists and no incentives for physicians to prescribe generic drugs. While 70 to 80 percent of all drugs used in Morocco are produced locally, generics are only 24 percent of the market (percentages are expressed in terms of number of units and not prices). 33 process across stakeholders and piloting as needed, together with deploying sufficient resources and developing the necessary legal, technical, and administrative competencies for results-based contractual agreements with regions and health facilities. 3.3 Reforming system governance and regulatory framework 49. Political commitment and leadership is essential. Improving governance of the health care system requires explicit political commitment to reform, backed by strong leadership and political will for a major realignment of the roles and responsibilities of MOH and health insurance agencies. The proposed alignment has two components: (i) Redefinition of MOH’s role and moving from being a service provider and a payer to being a policy maker, planner, standard setter, and regulator.44 This requires repositioning MOH and its administrative units vis-à-vis other ministries and government agencies, 45 its regional, provincial, and lower administrative units, 46 and ANAM. 47 MOH would have to leave financing and service provision and restructure itself to become an effective policy maker, planner, and regulator.48 (ii) Consolidating the mandate and functional responsibilities of ANAM, and strengthening its institutional capacity while increasing its autonomy. ANAM has a dual mandate, defined by Articles 59 and 60 of Law 65-00: (i) act as a regulatory agency for AMO in charge of oversight of its financial viability, regulation, and contractual negotiations with providers; and (ii) financial and administrative management of RAMED. It has two separate boards of administration, one for AMO and another for RAMED, each with its own configuration in terms of representation, distribution of power, and membership requirements. In both cases, ANAM, being under the tutelage of MOH, enjoys limited autonomy in making crucial policy decisions to harmonize obligations and entitlements.49 Under the current legal and regulatory framework ANAM does not have the authority to pool revenues under its tutelage and benefit from economies of scale, administrative simplicity, reduced administrative costs, or increased negotiation power vis-à-vis providers to truly become an active purchaser. 50 Increased autonomy would also allow ANAM to use RAMED as a testing ground, learn from experience, and build its institutional capacity by combining regulatory and management functions. Increased autonomy would also result in the separation of purchasing from provision and level the playing field between public and private providers, leading to more competition and better choice for patients.51 50. An explicit statement of vision is needed. While several reform initiatives have been launched that define broad strategic directions,52 there is a need for a “White Paper� with an explicit 44 “Steering rather than rowing� is an analogy often used to describe this shift in functional responsibilities. 45 In relation to human resources development, education and science, food hygiene and nutrition, water supply and sanitation, and biological, chemical, and environmental threats to health. 46 In relation to policy development, planning and performance evaluation for health, and health care issues of sub-national relevance and remit. 47 In relation to the harmonization and rationalization of the financing of the CMB and all related managerial, administrative, and monitoring and evaluation functions. 48 Several studies and audits review the institutional strengths and weaknesses of the MOH and its affiliated agencies and proposals have been made to restructure its central and regional organization. See the technical report financed by WHO and prepared by CREDES, issued in January 2006. 49 It is not ANAM, but CNOPS, its mutuelles and CNSS who are the main parties to decisions regarding premium rates on the revenue side, and the eligibility criteria, package of services, and co-payment rates for services rendered on the expenditure side. 50 Fragmentation of financing is so extensive that despite the recent attempts such as MTEF exercise and the budget program for the regions, it is impossible to allocate limited resources according to health needs, nor does the money follow the patient. 51 Rather than those covered by AMO using mainly private providers in large cities where the quality of care is undeniably better and those covered by RAMED having access to a less generous package of services available only in public facilities. 52 The “Horizon 2015� initiative defines 11 “Axes stratégiques� and the “Vision développement humain 2025� initiative identifies three prerequisites (purchaser provider split, defining national health policies, and developing a national health map). 34 statement of mid- and long-term vision, mission, policies and strategies, clearly delineating the role of the state and the nature and extent of the public-private mix in financing and service delivery. This is particularly crucial as the Palace and the Government increasingly recognize the dissatisfaction of the people with the democratization process. Morocco deserves to score and rank higher for the main health and human development indicators relative to its higher level of governance (Annex 8). Indeed, there seems to be genuine interest in increasing the legitimacy of the current governance structure, making it more accountable to the population, improving transparency, and curtailing corruption to maintain social peace and stability and respond to unmet human development needs, be they education, health or overall social protection, 35 CHAPTER 4: A WAY FORWARD 51. The success of any proposal for reform depends, first and foremost, on the accuracy of the diagnostics and the willingness to accept the final diagnosis. Overall, Morocco’s performance on human development in general and in health attainment and health system performance in particular compare unfavorably with those of countries at a similar level of socioeconomic development (Figure 4.1). This is especially so, because of inequalities in geographic, financial, socio-organizational access to quality heath care that result in a two-tiered healthcare system. In other words, it is not poverty and its determinants alone, but unresponsiveness, rather than inability, of the current healthcare system in providing the most essential healthcare services to the totality of the population.53 52. Our analysis shows that the lack of responsiveness has two sets of determinants: (i) those related to supply side issues, i.e., whether there is a health center within a walking distance to the settlers in a remote urban area where there is physician, a nurse and some amenities for the most essential care and these are accessible to any health care seeker either freely or at an acceptable price; and (ii) those related to demand side, i.e., whether the healthcare seeker will be cared for in a dignified manner54; that s/he will not be subject to any requests for informal payments or be denied of care simply because s/he cannot afford to pay for part or all of it; that’s/he will be given the necessary information which will improve his/her confidence in the technical competence of the provider and ensure his/her compliance with the prescription and counseling. The literature tells us that health care seeking behavior, itself has three sets of determinants: (i) those that predispose an individual to seek care, i.e., education, sex, attitudes and beliefs; (ii) the perceived need for healthcare, i.e., feeling or being ill or being told so; and (iii) those that enable the individual to actually demand healthcare, i.e., having an indigent card, or insurance and the tradeoff between the perceived benefits of seeking care and the time, cost and other inconveniences. Therefore, people will refrain from using health services, or from using them in a timely manner, unless they feel that they are “covered�, a necessary condition, but also if they believe that they are not going to be subject to arbitrariness or lower standards in the way technical and psycho-social care is provided, a sufficient condition. 53. In Morocco, the latter seems to be only partly a resource issue; but rather a governance issue, more than anything else, requiring thus measures beyond building more health facilities, training doctors, or simply increasing public budget for health, but rather empowering the patient in a way that the public funds will go to the provider of his/her choosing and leveling the playing field that that all providers, public or private, play by the same rules, or be subject to same entitlements, risks and obligations. How could this be done? 53 Poverty in Morocco is experienced as a complex of exclusion from economic, social, and political life as well as low income and poor access to services. Morocco as a country and society in transition the importance of a safety net for helping people to avoid spiraling into poverty during periods of illness or unemployment the problem of poor access to services (as opposed to simply the existence of services) - in health, for example, actual access is affected by corruption (Ref: Moving out of poverty, March 2007) 54 Health care: Many women are reticent to consult male health workers (particularly concerning reproductive health issues); this plus the fact that maternity facilities are often located in urban centers has puts women at real risk. This issue could be addressed by the more proactive encouragement of women to become rural health practitioners and improvements in affordability and physical access to quality reproductive health services and hospital facilities (Ref: Moving out of poverty, March 2007) 36 Figure 4.1: Health Status in Morocco relative to other Low- and High- Middle Income Countries In MENA and Other Regions, Trends 1990- 2005 Position Selected 1 2 3 4 5 6 7 8 9 10 11 12 Morocco country Lowest 1 Highest2 (2005) average (2005) (2005) (2005) Life expectancy at birth (years) 70.4 72.1 70.4 74.2 Infant mortality rate (per 1,000 live births) 36 24 14 36 Adult mortality rate (male) (per 1,000 male 156 172 151 237 adults)3 Adult mortality rate (female) (per 1,000 101 106 87 155 female adults)3 Births attended by skilled health personnel 63 82 63 100 (% of births)(*) Number of physicians per 1,000 0.5 1.5 0.5 3.3 population(*) Number of beds per 1,000 population 0.9 2.0 0.9 6.6 Public / private health expenditure ratio 0.52 1.49 0.38 6.14 Per capita total expenditure on health (in 234 388 109 817 international dollars) (**) Improvement in ranking of health indicators between 1990 and 2005 Note: The following countries were used as reference countries: Syria, Egypt, Jordan, Algeria, Iran, Tunisia, Lebanon, Oman, Colombia, Venezuela, Turkey, Romania. 1. Lowest value observed among twelve reference countries in 2005 or around 2005. 2. Highest value observed among twelve reference countries or around 2005. 3. Unstandardized mortality rates. (*) In 1990 Morocco ranked 9th out of nine countries for which data was available and 12th in 2005. (**) In 1990, Morocco ranked 9th out of ten countries for which data was available and 10th in 2005. 37 54. One could conceive the scope and purpose of health sector reform at four levels: (i) instrumental reforms to improve day-to-day management of the system, such as introducing and using various better information systems, new rules and standards for licensing facilities, or adopting new guidelines for rational use of drugs; (ii) organizational reforms to improve technical efficiency by focusing on productivity and quality of care to get better value for money within a given envelope, such as enforcing a gate-keeping and referral system, changing the mode of payment for physicians or hospitals; (iii) programmatic reforms, to improve allocative efficiency, or getting better value for public funds, such as introducing medium term budgeting, allocation of funds to high priority diseases or services; and (iv) systemic reforms to improve equity, mostly through changes in system governance encompassing a certain degree of realignment in the mandate, roles and responsibilities of the main stakeholders. 55. The attached policy matrix is prepared with the understanding that what is needed in Morocco is a systemic reform. It outlines the preoccupations and issues with the current health care system, defines the scope and purpose of the reform, lists a series of short- and long-term policy measures, identifies risks and prerequisites for adoptability and states at the end the outcome indiciators. Given the comprehensiveness of the reform agenda the role of the State will be primordial, Figure 4.2. below provides an example of how that role may change in the next decade and through what mechanisms. Figure 4.2: Changing Role of the State in Healthcare Main Functions Spain Egypt Turkey Morocco Morocco Remarks Today in 2020 (?) Policy/ ++++ ++++ ++++ +++++ ++++ Through more autonomy to Regulation ANAM Financing +++ +++ ++++ ++ ++++ Increased State Financing through RAMED and tax subsidies to SME Purchasing/ +++ +++ ++++ ++ +++ Through ANAM and indirectly Payment CNOPS and complementary private insurance Service Delivery ++++ ++++ +++ ++++ ++ Through increased autonomy to hospitals and public/private mix Organization/ +++ +++ +++ ++++ ++ Lesser involvement through Management regionalization Human Resources +++ +++ +++ +++++ +++ Liberalization of formal education in Development health sciences Legend: (+) minimal responsibility (+++++) exclusive responsibility N.B. Responsibility does not equate to actual fulfillment of the assigned role. 56. Successful implementation of the healthcare reform requires full support from all parties and proper sequencing. The first step of the process would be to issue the a draft policy document Santé –Vision 2020, followed by a consensus-building exercise among all stakeholders in the healthcare system. The second step would be the preparation of a timed-bound and costed implementation plan. Both of these steps, which are mainly political in nature, should have the backing of the Royal Court. The array of reform options should be fed back to all stakeholders to facilitate agreement on the timing, sequencing and financing of their implementation, as well as pre-requisites for their introduction (e.g., required legislation, regulation and training). A thoroughly consensual process needs to be followed including the population and the providers to explain what is stake, and jointly find the right levers and 38 mechanisms for full ownership. Two regions have demonstrated a high level of commitment to the reform process could then be selected to pilot the reforms. 57. Finally, a public information campaign, preferably conducted through the media, would be needed and should be developed and properly financed. The campaign should explain to the populations of the two regions the main tenets of the reform, the nature and timetable of reform activities and emphasize those actions likely to produce tangible results in the short run (e.g., improved access to and quality of care, as well as reduced out-of-pocket expenses for essential services). This step is very important to galvanize public support and help people understand and endure the distortions that are likely to occur during implementation of the reforms. A similar approach will be needed to fully inform health professionals and thus lessen misconceptions, alleviate fears, mitigate bureaucratic and professional resistance and assure their cooperation. Last but not least, collaboration with international partners throughout the process will be needed to secure their political, technical and financial support. 39 A policy matrix for improved health sector performance Preoccupation; Scope and purpose Policy Measures Risks Prerequisites Outcome indicators issue(s) for Short Term Long Term Adoptability EQUITY: SYSTEMIC: • Policies that • Harmonization of the BBP and patient • Political: • Political • Full • Protracted • Achievement of define the entitlements and obligations across (i) Divergent views commitment implementation inequalities in universal coverage eligibility CNOPS, CNSS, AMI-Inaya, on State’s role and from highest of CMB with a health and access in an equitable and criteria and RAMED and independent mutuelles. obligations in heath political virtual to healthcare in fiscally and the content of financing and level equity harmonization times of financially the Basic • Policy and guidelines for private service delivery; in access to and integration demographic and sustainable manner; Benefit sector involvement in service (ii) Disagreement care as a of population epidemiological • Fairness in Package for provision for all insured regardless of on the optimal human groups. transition. financial RAMED their affiliation. balance between the developmen contribution. beneficiaries. spread and breadth t goal. • Issuance of a long term Public of coverage for • Increased • Policy Investment Plan for all regions. RAMED, and its State measures that subsequent financing define the • Human resource deployment policy to harmonization with through eligibility improve socio-organizational access the current rights RAMED criteria and to care for women and children.55 and entitlements of and health the content of CNOPS and CNSS sector the Basic • Limiting the scope and boundaries of beneficiaries. investment Benefit private health insurance to exclude • Fiscal: in rural Package for BBP. In relation to Morocco. AMI-Inaya government beneficiaries. revenues and intersectoral trade- • Revision of offs in investment MOH mobile and expenditures. health care unit deployment policy for areas where geographic 55 This is mostly in relation to rural women of reproductive age who prefer being seen and examined by, or taking their children to, female doctors and other health professionals. 40 Preoccupation; Scope and purpose Policy Measures Risks Prerequisites Outcome indicators issue(s) for access is limited or non-existent. GOOD SYSTEMIC: • Adoption of • Redefinition of the institutional • Highly political: • Political • Functional GOVERNANCE: • Achievement of “Vision mandate and functional Significant reduction leadership, segmentation across • The governance pluralism in system 2020� responsibilities making ANAM the in MOH’s power base commitment MOH, ANAM and and institutional governance through sole policy setter and regulator in and sphere of and support providers through structure of the realignment of the • Policy health financing with CNOPS, influence. at the gradual separation healthcare system functional roles and decision on CNSS, AMI-Inaya becoming paying • Institutional: highest of financing, is fragmented, responsibilities the agents under the oversight of • ANAM’s current level. provision and reflecting the across of the main restructuring ANAM. institutional capacity • Constructive stewardship duality of the stake holders; of the MOH • Completion of regionalization with is not at par with the and functions. two-tiered system • Increased and revision the establishment of the remaining increased scope and consensual • Integration of with overlapping participation of of its seven socio-sanitary regions.57 responsibilities; attitude and revenue collection, roles and providers and mandate, • Completion of the on-going hospital • Sub-national self behavioral pooling and responsibilities consumers in roles and reform with full managerial and governance capacity response purchasing across providers system governance. responsibilitie financial autonomy. in the health sector is from all functions under and payers. • Responsiveness to s to reinforce • Redefinition of the privileges and limited. stake ANAM. expectations. its obligations of the Professional • Value-laden: holders. • Financial and stewardship, associations vis-à-vis self regulation, Citizen participation • Evaluation managerial regulatory licensing, certification, litigation and in system governance of the autonomy of all and representation in contractual is an emerging Regionalizat public and private population arrangements with ANAM. concept. ion Pilot health facilities. health and • Policy statement on consumer rights, Improved consumer system protection and obligations in system participation and intelligence management. protection. functions.56 56 Several technical proposals have been made to date, including organizational charts, but they need to be reviewed by the Government and eventually adopted. 57 A decree on “deconcentration� was adopted on December 2, 2005 and line ministries were asked to prepare their “schémas directeurs de déconcentration�. However, there still is soe confusion over the scope and extent of decentralization, i.e. political, managerial or simply administrative. At H.M King’s request a deconcentration strategy is being prepared by a task force which further delayed the implementation of the decree. In addition, the delineation of the socio-sanitary regions does not follow the administrative boundaries, thus further complicating its implementation. 41 Preoccupation; Scope and purpose Policy Measures Risks Prerequisites Outcome indicators issue(s) for ALLOCATIONAL PROGRAMMATIC: • Revision of the • Adoption of a “carte sanitaire�.59,60 Political: • Piloting new • Increased EFFICIENCY: • Health improvement Medium Term • Institutionalization of the “budget- • Lack of clarity programmin government • Low and poorly or attainment of the Expenditure program� as a policy tool for and/or disagreement g, financing and allocated public optimal health Framework58 improved resource allocation to on the role of the purchasing improved outlays for outcomes with the to include: newly established socio-sanitary State in the health and resource allocation of healthcare available resources, (i) a resource regions.61 sector; allocation public funds in resulting in or the “best value for allocation • Issuance of a financial and non- • Resistance to mechanisms line with the inefficiencies in money�. formula financial incentive package to relinquishing at the epidemiologic and resource allocation prorated by improve human resource deployment centralized power regional demographic and use, and high regional in Regional Health Departments and and authority; level. profile of the private OOP demographic rural ESSB.62 • Delays in public country and the expenditures. and socio- • Adoption of policies and institutional administration burden of risk epidemiologic mechanisms for improving price reform program.63 factors and profiles; setting and reimbursement rates for • Institutional: illness. (ii) within brand and generic drugs. • Bureaucratic regional resistance in MOH; allotments, • Limited capacity in outcome- the newly created based regions for planning programmatic and programming; budgeting • Delays in the public against administration regional health reform law and the objectives. reimbursement 58 MOH as a pilot line ministry already adopted a three year rolling MTEF for 2007-09, a successfully met trigger of PRAL-III. 59 In line with the revision of the “Plan d’Extension de Couverture Sanitaire, or PECS� and the extension of the “Schéma Régional de l’Offre de Soins (SROS) from three to all regions. 60 On the other hand, however, the MOH has not yet completed the drafting and approval of its “deconcentration master plan�, a trigger under the first PARL operation. 42 Preoccupation; Scope and purpose Policy Measures Risks Prerequisites Outcome indicators issue(s) for TECHNICAL ORGANIZATIONAL • Policy on • Adoption of a performance-based Political: • Piloting • Increased EFFICIENCY: : development provider payment policy and • Continent on the contractual population and • Low and/or • Responsiveness to and use of modalities for hospitals and progress with PARP. purchasing, provider uneven patient’s needs and (STPs) and physicians as a basis for contractual • Resistance from both QA/QC and satisfaction. productivity and expectations with the the agreements with the payers.66 public and private payment quality of care appropriate mix of applicable • Policy on medical malpractice and hospitals to mechanisms • Improved health resulting in medical, psycho- level of care; patient grievance (e.g., ombudsman). independent at the outcomes. suboptimal value social, • Policy on • Setting up an independent accreditation and regional for money and comprehensive and rational use accreditation agency. quality audits. level. provider and continuous care. of drugs • Licensing and accreditation of health Institutional: • A research patient • Policy on facilities as a pre-requisite for • ANAM’s current unit in dissatisfaction. inpatient contracting with ANAM. institutional capacity ANAM for care quality • ANAM empowered to conduct is limited vis-à-vis continuous improvemen technical quality audits. new purchasing monitoring t (QA/QC). • Review/revision of the Patient’s requirements and and research • Pay-for- Right Law. technical quality on trends, Performance audits; patterns and for • MOH’s current variations in physicians.64 organizational set up service use. • Revision of and capacity is not the fee conducive to schedule.65 carrying out acitivites related to accreditation and licensing. 61 MOH is the only line ministry that has so far been able to adopt a performance-based contracting with three regional authorities as part of the PARL-supported drive for greater responsibility in budgetary programming and execution for regional and provincial branch offices, with results accountability. 62 This should go hand in hand with MOH’s work on strategic staffing through the development of the “Référentiel des Emplois et des Compétences� or RECs, another trigger for PARL-III. 63 Especially with regard to civil service reform, wage policy and containment of public payroll. 64 This could be dovetailed to the ongoing government initiative to introduce performance evaluation in civil service for promotion and salary increases. Continuous medical education could be one of the prerequisites. 65 The update of the fee schedule has just been completed and fees are upwardly revised. However they need to be constantly updated on the basis of utilization patterns and new evidence on cost-effectiveness. 66 Please See Annex 6 and 7 for pros and cons of various payment schemes and examples from OECD countries. 43 Preoccupation; Scope and purpose Policy Measures Risks Prerequisites Outcome indicators issue(s) for INSTITUTIONAL MANAGERIAL: • Rigorous • Long-term human resources policy Political: • Constructive • Increased ENHANCEMENT; • Managerial, evaluation and strategy.67 • Delays in seeking and responsiveness to • Shortage and/or administrative and of hospital • E-government for improved public consensus on the consensual political, fiscal, uneven informational management services delivery and enhanced scope and reach of e- attitude and financial, medical, distribution of support for effective and budget transparency and anti- government. behavioral technological, qualified and and efficient information corruption.68 • Financial: response demographic and competent health stewardship and tools and • New State-funded research policy for Fiscal constraints to from all epidemiologic personnel and transparent policy needs-based attribution of grants. build up an “info- stake challenges. managers; governance. measures for structure�. holders. deficiencies and their wide- • Institutional: • Allocation of limited scale Harmonization of adequate transparency in implementat cost, patient and resources for collection, ion. medical information investment distribution and across all public and in “info- use of data and private payers and structure’. system providers. intelligence across all stakeholders. Limited country- specific health policy, system and services research for policy and decision support. 67 There already exists a HRD strategy but it needs to be expanded in scope to cover all allied health professionals and managers and IT system analysts as well as ANAM’s particular skills mix requirements. 68 In conjunction with the PARL-supported public administration reform program. Morocco has adopted a national strategy for ICT entitled Stratégie e-Maroc 2010, launched in 2001 by H.M. King Mohammed VI. E-Government is a key component of this strategy. A National Committee on e-Government was set up in 2003, chaired by the Minister for Public Sector Modernization to devise an action program known as IDARATI, Programme National e-Gouvernement 2005–08) and an implementation plan. 44 References Commission Européenne (2007). Rapport de revue/d’identification de l’appui de la Commission européenne a la consolidation de la couverture médicale de base au Maroc. Brussels, Belgium. EU Consultant Report (2006). “Rapport de revue/d’identification de l’appui de la Commission européenne a la consolidation de la couverture médicale de base au Maroc.� Gwatkin, Davidson R. et al (2005). “Socioeconomic Differences in Health, Nutrition and Population in Morocco, 2003/04.� World Bank, Washington, DC. Ottaway, M. Rily M (2006). Morocco: From Top-down Reform to Democratic Transition? Carnegie Endowment for International Peace. Washington, DC. Robalino, David A (2007). “Labor Market and Social Protection in Morocco.� Policy Note (Draft version, June 2007). Royaume du Maroc, Ministère de la santé (2006). “Santé, Vision 2015.� Rapport technique préparé par CREDES. Royaume du Maroc, Ministère de la santé (2006). “Stratégies proposées à l’Horizon 2015.� Septembre 2006. The Economist Intelligence Unit (2007). Morocco, Country Forecast, London, United Kingdom. Theme report on “Système de santé et qualité de vie� in the “50 Ans de Développement Humain – Perspective 2025.� http://www.rdh50.ma/fr/pdf/rapport_ thematique/Sante/systsantequdeviecorri.pdf Transparency Maroc: La corruption au Maroc (2002) : Synthèse des résultats des enquêtes d’intégrité. L’Université de Transparence. United Nations Development Program. 2006. Human Development Report 2006. New York: UNDP. Université de Montréal (2007). “Revue du système de santé au Maroc.� Consultant report, June 2007. Velenyi E.V (2007). Resource Allocation and Purchasing in the Middle East and North Africa (MNA) Region. A Regional Case Study in “Public Ends, Private Means: Strategic Purchasing of Health Services� Preker AS, Liu X, Velenyi EV and Baris E (Eds). 2007. Washington, DC. Waters, H. Rahola A, Hulme, J (2005): Health Insurance Expansion in Morocco. Draft Consultant Report, Washington, DC. World Bank (2006). Royaume du Maroc; Rapport sur la politique du médicament. Policy Note. Washington, DC. ——— “Rapport sur la fixation du prix des médicaments au Maroc.� World Bank, Washington, DC. World Bank (2007). “Third Public Administration Reform Adjustment Loan�. Initiating Memorandum, Draft Version (May 17, 2007). Washington, DC. World Bank (2007). “Youth – An Undervalued Asset: Towards a new Agenda in the Middle East and North Africa�, Policy Note. Draft version. Washington, DC. 45 World Bank (2007). “Moving out of Poverty in Morocco�. Policy Note. Washington, DC. World Bank (2007). “Skills Development and Social Protection within an Integrated Strategy for Employment Creation�, Draft version (May 2007). Washington, D.C. World Health Organization (2000). World Health Report, 2000. Geneva, Switzerland. World Health Organization (2005). “Country Profile Morocco.� Eastern Mediterranean Regional Office (EMRO), Cairo, Egypt World Health Organization (2006). “Mutuelles communautaires de santé ; Proposition de projet pilote. Rabat, Morocco. World Health Organization (2007). World Health Statistics 2007. Geneva, Switzerland. TO BE ADDED: The three EU documents Vision 2020 MTEF 08-10 MOH Human resources presentation Pharmaceuticals policy re New Law. Hospitals organization decree More emphasis on: More on l’allocation des resources hospitalieres PGFSS (nuances, e.g., SROS, PEH, etc) More Regionalisation More MOH reference Maybe more on hierarchisation des soins – cinq filieres aboutissant a un CHU. Piloting separation of power Perennisation du RAMED Cross cutting issues re reform of public administration; rural development, agriculture Accountability; public relations Horizontalite L’identification des indigents Experimentation du RAMED en cours; seulement hopitaux publics pour le moment; ticket moderateur; communatutes locales Augmentation du budget pour le RAMED a travers le MS MTEF 2008-2010. Il faut voir la morasse. 46 Annex 1: Progress with Achievement of MDGs in MENA How are MENA Countries doing? Prim ary Gender Acce ss to Child school e quality in Child Maternal HIV/AIDS w ate r & m alnutrition com pletion school m ortality m ortality prevale nce s anitation Ye m en, Rep. Djibouti Syrian Arab Re public Morocco Egypt, Arab Re p. Alge ria Wes t Bank and Gaza Iran, Is lam ic Re p. Jordan Tunis ia Le banon Iraq Libya Om an Saudi Arabia Bahrain Kuw ait Malta Qatar UAE Severely of f track: deteriorating trend, or needing tw ice as long or longer than MDG timef rame to reach goal Of f track: making progress, but not f ast enough to reach MDG by 2015 On track/Achieved: if progress made during the 1990s continues, w ill reach the MDG No reliable data available Source: World Bank, 2007 47 Annex 2: Health System Attainment and Performance in MENA, Spain and Turkey, 1997 ATTAINMENT OF GOALS PERFORMANCE On Health level expenditure Overall Fairness in Overall of Member State per capita in health Health Responsiveness financial goal health international system contribution attainment dollars Level performance Distribution Level (DALE) Distribution Algeria 84 110 90-91 50-52 74-75 99 114 45 81 Bahrain 61 72 43-44 3-38 61 58 48 30 42 Egypt 115 141 102 59 125-127 110 115 43 63 Iran, Islamic Republic of 96 113 100 93-94 112-113 114 94 58 93 Iraq 126 130 103-104 114 56-57 124 117 75 103 Jordan 101 83 84-86 53-57 49-50 84 98 100 83 Kuwait 68 54 29 3-38 30-32 46 41 68 45 Lebanon 95 88 55 79-81 101-102 93 46 97 91 Libyan Arab Jamahiriya 107 102 57-58 76 12-15 97 84 94 87 Mauritania 158 163 165-167 123 153 169 141 151 162 Morocco 110 111 151-153 67-68 125-127 94 99 17 29 Oman 72 59 83 49 56-57 59 62 1 8 Qatar 66 55 26-27 3-38 70 47 27 53 44 Saudi Arabia 58 70 67 50-52 37 61 63 10 26 Spain 5 11 34 3-38 26-29 19 24 6 7 Syrian Arab Republic 114 107 69-72 79-81 142-143 112 119 91 108 Tunisia 90 114 94 60-61 108-111 77 79 46 52 Turkey 73 109 93 66 49-50 96 82 33 70 United Arab Emirates 50 62 30 1 20-22 44 35 16 27 Yemen 141 165 180 189 135 146 182 82 120 Source: World Health Report, 2000, WHO, 2000 48 Annex 3: Demographic Profile in Morocco Population Growth Rate, 1980-2025 Composition of Population by Age Group, 1995-2025 3.0 80 70 2.5 60 2.0 50 40 1.5 30 20 1.0 10 0.5 0 1995 2000 2005 2010 2015 2020 2025 0.0 1980- 1985- 1990- 1995- 2000- 2005- 2010- 2015- 2020- Population < 15 Population 15-64 Population 65+ 1985 1990 1995 2000 2005 2010 2015 2020 2025 Trends in Total Fertility and Net Reproduction Rates, 1980- Trends in Dependency Ratios, 1980-2025 6.0 5.0 100 90 4.0 80 3.0 70 60 2.0 50 1.0 40 30 0.0 20 1980- 1985- 1990- 1995- 2000- 2005- 2010- 2015- 2020- 10 1985 1990 1995 2000 2005 2010 2015 2020 2025 0 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 T FR NPR 2025 T otal Child Old-age Morocco Age Pyramid 2005 Morocco Age Pyramid 2025 Morocco Population Estimate, 2005 Morocco Population Estimate, 2025 70-74 70-74 Male Female Male Female 60-64 60-64 50-54 50-54 40-44 Age 40-44 Age 30-34 30-34 20-24 20-24 10-14 10-14 0-4 0-4 15 10 5 0 5 10 15 15 10 5 0 5 10 15 % of Population % of Population Source: UN Population Division, World Population Prospects: The 2006 Revision Population Database 49 Annex 4: Inequalities in Health, Morocco, 2003-2004 Wealth Quintiles Population Low/High Indicator Low Second Middle Fourth High Average Ratio HNP Status Indicators IMR 62.2 53.1 36.8 33.4 24.0 44.0 2.59 U5MR 77.6 65.5 46.7 37.3 26.1 53.6 2.98 Children stunted (% moderate) 17.2 12.4 11.6 7.8 6.9 11.7 2.50 Children underweight (% moderate) 13.2 8.3 7.7 6.9 2.9 8.2 4.57 Women malnutrition (%) 7.8 7.9 7.1 6.9 5.7 7.0 1.37 Total fertility rate 3.3 3.1 2.5 1.8 1.9 2.5 1.70 Adolescent fertility rate 50.7 35.7 44.3 21.0 12.5 32.4 4.05 HNP service indicators Childhood immunization coverage (%): -- Measles 83.1 87.2 91.3 96.7 97.5 90.5 0.85 -- DPT3 89.0 94.9 96.7 97.1 98.1 94.9 0.91 -- Full basic coverage 80.7 85.7 90.6 95.6 97.3 89.3 0.83 -- No basic coverage 2.8 1.9 0.4 0.7 0.7 1.4 3.98 Treatment of childhood illnesses Treatment of fever (%): -- medical treatment of fever 18.7 33.4 31.6 42.9 50.8 34.3 0.37 -- treatment in a public facility 17.0 30.2 27.6 33.0 22.3 26.1 0.76 -- treatment in a private facility 1.7 3.3 4.0 9.9 28.5 8.1 0.06 Treatment of diarrhea (%): -- use of oral rehydration therapy 43.1 55.2 59.1 59.4 57.1 54.0 0.75 -- medical treatment of diarrhea 14.5 19.6 25.6 28.3 27.4 22.1 0.53 -- treatment in a public facility 13.9 16.1 24.6 21.8 15,3 18.2 0.91 -- treatment in a private facility 0.6 3.6 1.1 6.6 12.1 4.0 0.05 Treatment of Acute Respiratory Infection (%): -- medical treatment of ARI 19.2 34.1 37.0 52.9 58.1 37.8 0.33 -- treatment in a public facility 17.3 27.0 33.4 31.7 28.5 27.1 0.61 -- treatment in a private facility 1.9 7.1 3.6 21.2 29.6 10.7 0.06 Antenatal Care Visits (%): -- to a medically trained person 39.7 56.4 70.6 86.8 93.1 67.8 0.43 -- to a doctor 17.1 24.8 35.9 53.3 78.7 40.2 0.22 -- to a nurse or trained midwife 22.6 31.7 34.7 33.5 14.4 27.6 1.57 -- multiple visits to a medically trained person 20.7 38.1 52.5 71.0 82.3 51.1 0.25 -- iron supplementation 17.3 28.7 37.9 49.7 64.6 38.3 0.27 Delivery Attendance (%): -- by a medically trained person 29.4 49.4 70.3 86.1 95.4 62.6 0.31 -- by a doctor 4.3 5.8 14.0 20.7 43.1 15.7 0.10 -- by a nurse or trained midwife 25.2 43.6 56.3 65.4 52.3 46.9 0.48 -- % in a public facility 28.3 47.0 65.8 74.4 59.6 53.0 0.47 -- % in a private facility 0.1 0.8 1.9 9.3 34.2 7.8 0.00 -- % at home 70.5 51.4 31.8 15.9 6.0 38.5 11.84 Contraceptive prevalence -- Females 51.4 55.2 55.4 54.8 56.8 54.8 0.90 Source: Davidson R. Gwatkin et al. 2005. Socioeconomic Differences in Health, Nutrition and Population in Morocco, 2003/04. 50 Annex 5: Levels and Composition of Health Expenditures in WB Regions and Income Categories, 2004 Regions Per Per Per capita Total health Public health Social Private Out of Out of External capita capita health expenditures expenditures security as % health pocket as pocket resources GDP1 health expenditures (THE) (PHE) as % of public expenditure % of private as % of total as % of total (US$) expendi (PPP as % GDP of total health health as % of total health health health tures1 adjusted) expenditure expenditure health expenditure expenditure expenditure (US$) expenditure EAP 1,267 64 276 5.1 37.5 42.8 62.5 84.2 52.7 0.9 ECA 2,976 194 521 6.2 62.0 43.8 38.0 81.2 30.8 1.3 LAC 3,325 225 535 6.9 49.3 33.1 50.7 72.7 36.8 1.1 South Asia 545 24 122 4.4 26.1 8.9 73.9 95.8 70.8 2.9 SSA 608 38 116 5.2 40.8 4.9 59.2 80.1 47.4 14.8 MNA 2,360 101 289 5.7 47.4 22.6 52.6 86.4 45.4 1.1 Income levels Low income 481 22 102 4.6 31.2 7.7 68.8 91.9 63.2 7.1 Lower middle 1,659 97 342 5.6 43.6 38.3 56.4 81.1 45.7 0.6 income Upper middle 5,596 341 677 6.4 55.5 56.8 44.5 79.0 35.1 0.3 income High income 30,811 3,466 3,427 10.7 64.8 43.3 35.2 57.0 20.1 0.0 Global 5,969 602 752 6.0 42.9 29.0 57.1 81.3 46.5 2.9 average Morocco 4,309 82 234 5.1 34.3 0.0 65.7 76.0 49.9 0.9 Algeria 6,603 63 226 3.6 72.5 33.2 27.5 94.6 26.0 0.0 Tunisia 7,768 175 502 6.2 52.1 19.4 47.9 83.0 39.8 0.2 Jordan 4,688 200 502 9.8 48.4 0.5 51.6 73.8 38.1 7.1 Egypt 4,211 66 258 6.1 38.2 26.7 61.8 94.3 58.3 0.9 Spain 25,047 1971 2,099 8.1 70.9 7.4 29.1 81.0 23.6 0.0 Sources: World Bank 2006 and World Health Organization 2007. Morocco, Algeria, Tunisia, Jordan, Egypt and Spain: Per capita health expenditure PPP adjusted. Source: UNDP, 2000 data Per Capita HE, THE as % of GDP, Public Health Expenditure as % of GDP, Private Health Expenditure as % of THE. Source: WHO, 2004 data Per Capita GDP: constant 2000 US$. Source: World Bank Out of pocket as % of total health expenditure. Source: WHO, 2004 data Social security as % of public health expenditure. Source: WHO, 2004 data External resources as % of total health expenditure. Source: WHO, 2004 data 1 Adjusted by exchange rates, except for Morocco, Algeria, Tunisia, Jordan, Egypt and Spain where it represents GDP in PPP for 2004. 51 Annex 6: Resource Allocation for Improved Efficiency Population- Population- Facility- Facility- Case mix Global Line-by-line Line- by- Policy Project- Project- Ministerial based based based based based discretion Demographic Size, Case and or Factor Factors To address Single Self- Epidemiological type, or service applied to a applied on a to specific healthcare explanatory Socio-economic vocation, volume and previous line-by-line policy organization location of intensity spending basis to initiatives for one time the facility figure previous cost funding estimates Outcome Outcome Outcome Outcome Output Outcome Output Outcome oriented oriented oriented oriented oriented oriented oriented oriented Ability to Ability to Ability to Ability to Ability to Ability to Ability to Ability to respond respond respond respond respond respond respond respond changes changes changes changes changes changes changes changes High High High High Low Low Low Medium Stability of Stability Stability of Stability of Stability of Stability of Stability of Stability of funding of funding funding funding funding funding funding funding High High High Medium Medium Low Low Low Adapted from: McKillop I: Financial Rules as a Catalyst for Change in the Canadian Health Care System. Discussion Paper No. 19. Commission on the Future of Health Care in Canada, Sept 2002 52 Annex 7: Hospital Payment Mechanisms: Incentives and Risks P aym en t B asket o f R isk b o rn e b y P ro v id er ince ntive s to m e cha nism se rvice s p aid fo r p aye r b y p ro vid er in cre ase d e crease inc re ase select no . o f ac tivity rep o rted he alth ie r p atients per illn ess p a tien ts co nsu l- sev erity tatio n eac h agree d item o f a ll risk b o rne no risk b o rn e FFS yes no yes no se rvice a nd b y p ayer b y p ro vid er co n sultatio n risk o f n o . o f C a se p aym ent risk o f co st o f c ases an d p aym e nt ra te s vary b y treatm en t fo r yes ye s yes yes sev erity (e.g. D R G ) case a given ca se c la ssific atio n risk o f risk o f no . o f eac h A d m issio n n um b e r o f service s p er yes ye s no yes ad m issio n a d m issio n s ad m issio n risk o f risk o f co st o f eac h p atie nt P er d iem n um b e r o f service s p er yes ye s no no d ay d ays d ay all co vered all risk b o rn e se rvice s fo r a m o un t ab o ve b y p ro vid er C a p ita tio n o ne p erso n ‘sto p -lo ss’ up to a g ive n yes n/a no yes in a give n c eiling ceiling (sto p - p erio d lo ss) G lo b a l all se rvice s n o risk b o rne all risk b o rn e no n/a n/a yes b ud ge t p ro vid ed b y b y th e p aye r b y p ro vid er an institutio n in a give n p erio d 53 Annex 8: Governance and Human Development in Morocco. 2005 Figure 1: GRIS Composite Index and IMR, 2005 Figure 2: GRIS Composite Index and U5MR, 2005 70 80 y = 38.849e-0.0165x 60 y = 43.639e-0.0156x IMR (per 1,000 live births) R2 = 0.2297 70 U5MR (per 1,000 live births) 50 R2 = 0.2204 60 Morocco 40 50 Morocco Iran Egypt Iran Turkey Egypt 30 40 Lebanon Jordan Turkey 20 30 Lebanon Colom bia Jordan 20 Colom bia 10 Tunisia Tunisia 10 0 0 10 20 30 40 50 60 70 80 0 0 10 20 30 40 50 60 70 80 GRIS composite i nde x (pe rce ntile ) GRIS composite index (pe rcentile) Figure 3: GRIS Composite Index and Life Figure 4: GRIS Composite Index 2005 and HDI Expectancy, 2005 2004 76 140 Morocco 75 y = 119.86e-0.0112x Life Expectancy at birth (years) Egypt Tunisia 120 74 Colombia 73 Iran Turkey R2 = 0.2824 Lebanon 100 72 Tunisia Jordan Lebanon HDI Rank 71 80 Jordan Turkey 70 Iran Egypt 60 Colom bia 69 Morocco 0.0003x 68 y = 71.222e 40 67 R 2 = 0.0276 20 66 65 0 0 10 20 30 40 50 60 70 80 0 10 20 30 40 50 60 70 80 GRIS composite index (perce ntile ) GRIS composite inde x (pe rce ntile ) Figure 8.5: GRIS Composite Index and Per Capita GDP (PPP), 2005 80 GRIS composite index (percentile) 70 60 Jordan Turkey Tunisia 50 Lebanon 40 Morocco Colom bia Egypt 30 y = 0.0031x + 17.945 20 R2 = 0.4419 10 Iran 0 0 2000 4000 6000 8000 10000 12000 14000 16000 Pe r Capita GDP, 2005, PPP Source: UNICEF State of the World Children 2007, Kaufmann, D., A. Kraay, and M. Mastruzzi 2003: Governance Matters III: Governance Indicators for 1996-2005. 54 Table 8.1: Governance Research Indicators of Selected Middle Income Countries in the MENA and other regions MENA Voice & Accountability Political Stability Government Effectiveness Regulatory Quality Rule of Law Control of Corruption Composite[1] HDI Rank 1996 2005 1996 2005 1996 2005 1996 2005 1996 2005 1996 2005 1996 2005 2004 Lower Middle Income Countries Syria 9.1 5.8 21.2 20.3 25.7 8.6 18.6 10.4 31.6 42.5 25.4 36.9 21.9 20.8 107 Egypt 25.0 18.4 25.5 21.2 48.6 43.1 44.6 34.7 60.3 54.6 62.9 43.3 44.5 35.9 111 Morocco 27.4 26.6 27.4 31.6 58.6 48.3 52.0 39.1 59.3 51.7 65.4 54.7 48.4 42.0 123 Jordan 44.7 27.5 50.5 35.8 63.3 57.9 51.0 57.9 59.8 62.3 58.0 65.5 54.6 51.2 86 Algeria 14.4 24.6 0.5 17.9 31.9 42.6 18.1 26.2 30.1 31.9 42.4 42.4 22.9 30.9 102 WBG 2.9 13.5 N/A 5.2 N/A 11.0 N/A 12.9 N/A 39.1 N/A 9.9 N/A 15.3 100 Iran 17.3 9.7 25.9 16.0 42.4 26.3 6.4 6.9 20.1 29.0 18.5 41.4 21.8 21.6 96 Tunisia 30.3 18.8 46.2 49.5 71.4 67.0 60.3 51.5 56.9 58.5 59.5 60.1 54.1 50.9 87 Brazil 55.3 57.0 31.6 40.6 51.4 55.0 53.4 55.0 46.4 43.0 57.1 48.3 49.2 49.8 69 Colombia 47.1 36.7 7.5 4.2 65.7 53.1 66.7 54.0 34.4 32.4 35.6 53.2 42.8 38.9 70 Ukraine 36.1 40.1 30.2 32.1 18.1 40.2 24.0 47.0 28.2 34.8 23.9 34.5 26.8 38.1 77 Ecuador 51.4 41.5 19.3 22.6 13.3 13.9 48.5 20.8 36.4 22.7 23.4 24.6 32.1 24.4 83 Kazakhstan 19.2 15.0 34.9 46.7 12.4 29.2 31.9 35.1 23.0 26.6 18.0 18.2 23.2 28.5 79 Upper Middle Income Countries Lebanon 34.1 28.5 26.9 15.6 46.7 46.4 58.3 44.1 45.5 44.4 51.7 44.8 43.9 37.3 78 Oman 27.9 23.2 62.3 73.1 78.6 67.9 69.1 65.8 83.7 71.0 64.4 72.9 64.3 62.3 56 Argentina 64.9 59.4 51.4 37.7 78.1 47.8 78.4 25.2 62.2 36.2 54.1 41.9 64.9 41.4 36 Poland 76.0 83.6 53.8 54.2 72.4 71.3 63.2 72.3 65.6 59.9 73.2 61.1 67.4 67.1 37 Malaysia 48.1 34.3 73.1 62.3 79.5 80.4 80.4 66.8 78.5 66.2 75.6 64.5 72.5 62.4 61 Romania 50.5 56.5 52.4 46.2 17.1 56.9 25.0 58.4 44.5 45.4 51.2 51.7 40.1 52.5 60 Turkey 34.6 46.4 9.9 29.7 55.7 63.2 67.2 58.9 56.0 55.6 62.0 59.6 47.6 52.2 92 Venezuela 51.0 31.9 17.9 11.8 20.5 23.0 37.3 12.4 28.7 9.2 24.9 16.7 30.1 17.5 72 MENA 24 24.8 34.8 35 51.1 45 41.7 41.8 50.8 50.3 49 52.1 43.3 41.5 91 Source: Kaufmann, D., A. Kraay, and M. Mastruzzi 2003: Governance Matters III: Governance Indicators for 1996-2005.69 69 Note: The governance indicators presented here reflect the statistical compilation of responses on the quality of governance given by a large number of enterprise, citizen and expert survey respondents in industrial and developing countries, as reported by a number of survey institutes, think tanks, non-governmental organizations, and international organizations. The aggregate indicators in no way reflect the official position of the World Bank, its Executive Directors, or the countries they represent. As discussed in detail in the accompanying papers, countries' relative positions on these indicators are subject to margins of error that are clearly indicated. Consequently, precise country rankings should not be inferred from this data (Kaufmann et al 2003, http://info.worldbank.org/beeps/kkz/gov2001map.asp). 55