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Morocco : leapfrog without the basics?

The digitalization of Moroccan's healthcare system

« Morocco has yet to improve its public health services. » This was revealed in a 2017 study by the British medical journal, The Lancet. At the end of 2019, what is the current state of this healthcare system? What is the place of e-health and of the various digital initiatives?

« Morocco’s healthcare system is close to France’s one… in the 70s. »

What are the main observations on hospitals’ general organization in Morocco?

Unlike France where hospitals enjoy a certain autonomy and their own budgets to carry out projects, in Morocco, excepting University Hospitals, public hospitals are not autonomous and have reduced budgets. The consulting studies carried out by the firm I interviewed are therefore often the result of foreign funding (European initiatives for example) or come directly from requests from the Ministry of Health.
Two main elements are at the root of the problems linked to health reforms in Morocco: the first is the organization chart and the complex operating model of the Ministry of Health, which has remained the same for years. A second is human-related and involves the bureaucracy and individual priorities. However, two health system reforms have taken place: the first around 2000, and the second, which is still ongoing. 
Despite this, little has changed. There is a huge gap between the media aspect and the reality of the field: a concrete example is that of telemedicine: in 2017-2018, due to the gain of in interest in telemedicine, Mohammed VI University set up the Moroccan society of telemedicine. Following that took place a call for tenders for a teleconsultation project in some landlocked villages around 2018, and a solution was chosen for a 6-month trial period. Moroccan legislation has even evolved to take account of these innovations: a law text making it possible to supervise teleconsultation indeed passed in 2018. However since then: no news concerning the experimentation.
This problem is an example of a more global issue, that of the generalization of initiatives at national level. Many projects are carried out locally, but are struggling to spread.

« Funding surfs on current trends, telemedicine, blockchain, but the basis, the information system, is the essential and missing brick. »

The missing prerequisite is an integrated information system. Currently, the majority of files are in paper format, with often little follow-up even within the same hospital. A new file is recreated at each visit. In addition, there is no single number per patient, only a national card number. A single social register is being created to begin to alleviate this problem.
Additionally,  many hospitals are an IT desert, with at best an office suite but no other applications. In addition, the Internet does not reach all remote towns, so consideration should already be given to improving infrastructure or adapting solutions to local reality (satellite transmission for example). The Ministry of Health has tried to launch a first application, but it does not work well, and it is not accessible through the internet (local only). 
Funding surfs on fashionable products (telemedicine, blockchain), rather than according to top priorities. However, if the skills exist, funding is one of the major blocking points for the digital transformation of hospitals. This observation is the same in some other African countries such as Mali, Burkina Faso, Niger, or Guinea: these countries are far ahead of certain technology niches, but there is no consistent and widespread experience across the country.
In the private sector, hospitals are better off on average, with a few applications and computer systems

Added to this are economic problems

Regarding basic medical coverage, 3 regimes coexist in Morocco: private, public and an equivalent of the French « CMU », for the poor and the vulnerable.
If only 64% of the population only has health insurance cover, in terms of health expenses, reimbursement is based on 2006 rates. It means that there is therefore a substantial out of pocket for the patient. For example, a consultation with a general practitioner costs around 250 dirhams now vs. 150 dirhams in the past. As the reimbursement is based on the old rate, it results in about 50% of out of pocket for the patient.
However, the two CNSS and CNOPS funds are, or are close to the technical deficit. Due to this funding problem, they cannot upgrade national pricing.
This economic context complicates the implementation and the priorities assigned to health projects

Innovation getting away…inside

University Hospitals have financial autonomy and establish their own action plan.Rabat hosted the first University Hospital (UH), then a new one was created in Casablanca. Once the Casablanca UH reached saturation, the Marrakech and Fes UHs were created, at the heart of innovation. And similarly, once these UHs were saturated, the researchers left for 2 new UHs in Tangier and Agadir… This phenomenon of gradual departures displaces talent and innovation.
In Casablanca, the creation by the Cheikh Khalifa foundation of the Mohammed VI University of social sciences, private, thus boosted innovation. With a budget, 90% of scientific events take place there (and not at Hassan II University or the University of Medicine).

Cooperation between African countries?

South-South cooperation is very active in the healthcare sector: a cooperation division is established at the level of the Ministry of Health (activities take, for example, the form of patient transfers to certain UHs in Morocco).
Twinning also strengthens the links between hospitals in Morocco and abroad. For example, Rabat’s UH benefits from several partnership agreements both in terms of training and exchange of good practices. The national school of public health trains many doctors from other African countries.
Finally, medical tourism is a reality: less important than in Tunisia (more focused on aesthetics), Morocco targets the rest of the African continent on heavier and more specific pathologies.

What’s next?

Morocco is the cradle of many great projects and initiatives, but there is a need to strengthen the foundations to better support innovations afterwards. The patient journey and the creation of a monitoring tool is a first step.These improvements could also help reduce spending and allocate budgets for essential projects to improve care for Moroccans. Collaboration between countries in Africa is also a perspective to be studied in this context.

This article is the fruit of my own analysis following a discussion with Mr. Najib DIOURI, director of Alium Santé Maroc whom I thank. I am ultimately accountable for this article’s content.
Alium Santé is a French consulting firm in strategy and organization of health and medico-social establishments.The range of missions is broader in Morocco, with more activity in terms of public advice versus hospital management. The firm operates mainly in the public. Among the clients are the WHO, the World Bank or the Ministry of Health, with central issues such as mother and child health, reproductive health, medical care for victims of violence.

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