Paper Exploring Morocco's Expanded Health Insurance Coverage

A research paper co-authored by Jennifer Prah Ruger, assistant professor of Global Health in the Department of Epidemiology and Public Health at Yale School of Medicine, and Daniel Kress, senior program officer of the Bill and Melinda Gates Foundation, reported major milestones in health status, health care delivery and financing to expand health insurance coverage in Morocco.  The results of this study and others were presented at the Health Affairs Briefing: Financing and Improving Global Health Care held at the National Press Club in Washington, D.C. on July 16, 2007.

The authors were optimistic about the future potential of closing health system gaps in Morocco and the valuable lessons that could be gleaned for both developing and developed countries worldwide, although they still found some inadequacies in the health care system.

Published in a special theme issue on financing and improving global health care in Health Affairs, the authors analyzed two reforms approved by the government of Morocco in 2005 and the historical debate leading to the reforms. 

Ruger stated, “The Moroccan experience demonstrates the importance of combining scientific evidence on health system access and financing with ethical values of equity and solidarity in achieving health policy reforms.”

The program was designed to improve access to high-quality care and reduce disparities in access and financing between income groups and between rural and urban dwellers. These reforms included l’Assurance Maladie Obligatoire (AMO), a payroll-based mandatory health insurance plan to extend coverage from 16 percent to 30 percent of the population, and Regime d’Assistance Medicale (RAMED), a publicly financed fund to cover services for the poor.  The authors also explored prospects and future challenges for implementation of the reforms.

National health insurance has been broadly debated by Moroccans over the last fifteen years.  One major theme in the debate has been rethinking the role of the Moroccan government. Despite the competing interests raised by various constituencies, a consensus was reached to include greater solidarity and equity in access to high-quality care and additional financial resources and government oversight to help attain these goals.

As a result of analyzing the government of Morocco’s health system configuration and infrastructure, health insurance coverage, the national debate on health insurance, and the results of phasing in policy reforms AMO and RAMED, the authors concluded  that despite positive trends in developing its health system capacity and dealing with communicable disease over the past three decades, there are still gaps in health status, access, utilization, quality, and financial protection between the rich and poor and between urban and rural areas. 

Ruger and Kress offered recommendations to help the government of Morocco fully realize the success of both the AMO and RAMED reforms.  Their recommendations included significantly increasing the amount of public resources devoted to health care, a change in the distribution of public resources among regions, populations and providers, and a guarantee for adequate finances to local authorities, especially in rural areas.  To pool and adjust for risk across populations, they also recommended an integration of public and employer-related financing sources, social security and regulatory agencies.

Ruger concluded, “Like many countries, Morocco’s reforms demonstrate the long and arduous process of consensus building on policy design. The implementation period requires developing the financial, physical, human resource and institutional capacity to achieve results on the ground.  The Moroccan government is well-poised to achieve these objectives.”

Founded by Charles-Edward Amory Winslow in 1915, the Department of Epidemiology and Public Health at Yale School of Medicine, is one of the country's oldest programs in public health.  It has played a pivotal role in defining and addressing public health issues and training leaders in public health research, education and practice. The Department provides leadership to protect and improve the health of the public. Through innovative research, policy analysis, and education that draw upon multidisciplinary scholarship from across the graduate and professional programs at Yale, the Department of Epidemiology and Public Health at Yale School of Medicine, serves local, national, and international communities with its knowledge and expertise.

Citation: Health Affairs 26(4): 1009-1016 (July 2007)