25 MARTINDALE CENTER FOR THE STUDY OF PRIVATE ENTERPRISE Existing health-care coverage The Moroccan national health system is made up of public, private nonprofit, and private for-profit sectors. The public sector encompasses the Ministry of Health and Social Protection as well as health services for the Royal Armed Forces. That ministry implements health policies established by the Moroccan government through hospital networks and PHC facilities. The private nonprofit sector includes the Caisse Nationale de Sécurité Sociale (CNSS) (National Social Security Fund). The private for-profit sector comprises a variety of health-care facilities, such as clinics, consultation offices, medical analysis laboratories, and dental offices (Zahidi et al., 2022). In 2002, the Moroccan government passed Law 65-00, establishing a basic medical coverage system that includes two distinct insurance plans: mandatory health insurance (Assurance Maladie Obligatoire [AMO] [Compulsory Health Insurance]) and a plan for those in the informal sector or populations not covered by the compulsory coverage (Régime d’Assistance Médicale [RAMED] [Medical Assistance Plan]) (Zahidi et al., 2022). AMO, introduced in 2005, is mandatory for employees and pensioners in both the public and private sectors. Its coverage ranges from 70% to 90% of the national reference rate (a rate set by each county that is used as a point of comparison), including maternity care, radiology, outpatient care, dental care, long-term illnesses, hospitalizations, eye care, medicine reimbursements, and oral care (ACAPS, n.d.). The AMO is divided into two national security funds that provide insurance for employees in certain sectors: the CNSS for private sector employees and pensioners and the National Fund of Social Welfare Organizations for state employees, Moroccan students, beneficiaries of CNSS services before AMO, and beneficiaries of voluntary leave (ACAPS, n.d.). In addition, participants in the CNSS do have the option to subscribe to private insurance. Citizens may decide to use private insurance because of the advanced quality of care that can be received at private facilities, indicating a gap in quality of care. Currently, reimbursement rates and benefit packages for both AMO funds are unequal, and these discrepancies are causing the health-care utilization rate to fluctuate between the two groups. The reimbursement rate for CNSS is lower than the reimbursement rate for the National Fund of Social Welfare Organizations in all types of medical services. As a result, that rate is 45% in the public sector and 18.5% in the private sector (Cheikh et al., 2019). Reimbursement rates for both funds must be matched for equal access to quality care; otherwise, the health-care utilization rate will continue to be unequal between the two groups. RAMED, introduced in 2012, is for those working in the informal sector, and “those without sufficient resources to meet the costs of medical care, persons with disabilities unable to fulfill remunerated activity, residents of charitable institutions, hospices, and orphanages” (UN ESCAP, 2019). In 2017, an evaluation by the National Observatory for Human Development concluded that while RAMED is a helpful resource for reducing social inequalities in access to care, the program’s funding is problematic, adding strain on public hospitals; more importantly, the poorest social group is still not included in this plan (Zahidi et al., 2022). Currently, there are multiple systems in place catering to different groups of people. Each system, however, has varying levels of accessibility and quality, and 50% to 63% of the costs fall to the patients (Kasraoui, 2023, June 19). UHC does not propose implementing a single system for comprehensive access. Instead, it will enable adjustments that permit Morocco to incorporate the existing AMO and RAMED systems, thereby avoiding the need for extensive restructuring. Current interventions Morocco has developed some strategies to achieve UHC, incorporating suggestions from the King, the Ministry of Health and Social Protection, and the UN. Each of these plans outlines specific actions to move the country away from the current unequal health-care system to a system where everyone can access health care, regardless of an individual’s social determinants of health, including socioeconomic status, neighborhood, or occupation. In 2018, the Ministry of Health and Social Protection developed a comprehensive health plan to guide the country toward UHC. The Santé (Health) 2025 plan, based on guidance from the royal family, current global health trends, and previous commitments to governmental initiatives, is structured around three fundamental pillars. The first pillar aims to establish and enhance accessible health services for all individuals. This pillar includes measures to reduce the cost of medications, establish virtual health-care services, and restructure the public hospital network. Additionally, this pillar emphasizes the adoption of family medicine and the rehabilitation of general medicine. The second pillar focuses on fortifying national health and disease control programs. This pillar includes plans to strengthen prevention programs and enhance health monitoring, to reduce the inci-
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