MEDI1TV Afrique : Généralisation de la couverture sanitaire : Analyse du diagnostic du CESE - 22/11/2024
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00:00Good evening, ladies and gentlemen, analysis and conclusion of the diagnostic of the
00:17Economic, Social and Environmental Council on the generalization of health coverage
00:22under the eye of our analysts this evening.
00:24And this figure that comes out of this first step assessment, nearly a quarter of Moroccans
00:29are still not covered, three years after the launch of this ambitious program by the
00:36government, following the instructions of His Majesty the King Mohammed VI.
00:40We learn from this report of the Council that 3.5 million registered cannot benefit from
00:45any coverage because they do not contribute.
00:48To this is added the weak adherence to the principles of the law and bad news, half
00:54of non-government citizens are not predisposed to sign up.
00:57And then for those who are already insured, only 8% aspire to additional coverage.
01:03In these many recommendations, the Council recommends legislative, regulatory and technical
01:09reforms to make health insurance more accessible and above all more effective, and calls
01:15on this area of governance to create a universal national regime mandatory of base
01:21which would be managed by a public body dedicated to this branch of social security.
01:26Also, we recommend the separation of the management of recipes and care.
01:30In short, this site is titanic, to cover the health needs of all Moroccans,
01:36of all Moroccans and of all Moroccans is halfway, and therefore requires a step-by-step assessment
01:41that we will discuss with my guests tonight.
01:44First, I will start with the professor of law and political science, Mustapha Semi.
01:50Good evening, Professor Semi.
01:51Good evening.
01:52And with us, the professor of economics at the University of Marseille, Professor Zechariah
01:56Ferrano.
01:57Good evening and welcome to this set.
01:58Good evening, thank you.
01:59First, gentlemen, why a step-by-step assessment, why an opinion, this self-seize of the ICC
02:05on the work of the generalization of universal health coverage?
02:09Professor Semi.
02:10I would be tempted to tell you why not, but it's not an answer.
02:14It could be.
02:15What is interesting to note is that it is a report signed, it is probably the last
02:21report signed by Ahmadinejad, who was appointed by His Majesty the Great Ambassador to the
02:27European Union.
02:28It is an interesting report.
02:30It intervenes in full debate on the 2025 financial law project.
02:36It addresses the conditions in which social protection declines, in particular for this
02:44period.
02:45And then I have to say this, it is a forty-page report.
02:50It is difficult to say, I will be nuanced, it is difficult to say that it is a satisfaction
02:56given to the policy of this government.
02:59And it deserves a debate.
03:01You take this report, you read it, there are a number of observations that are made
03:08by this Council.
03:11I have to say that it is a fundamental work, a quality work, a fundamental work that has
03:17put in place a number of files, instances, and at the same time…
03:21You are talking about satisfaction.
03:23It is not satisfactory.
03:24Ah, it is not, OK.
03:25No, no, it is not satisfactory for the policy carried out by this government, especially
03:30since this government distinguishes itself by an obstinately optimistic rhetoric.
03:37We saw it during the presentation of the financial law project, we saw it in the declarations
03:42of the Chief Executive, etc.
03:44So it is a file that brings things back to where they should be.
03:49That is to say, an objective assessment of the state of this file, its progress, its
03:53blockages, its difficulties, and at the same time its perspectives and reform paths.
03:57Objectively, if we say that today 31.8 million Moroccans benefit from a minimum
04:05medical coverage, which is about 87% of the population, compared to less than 60% in 2020,
04:12it is a good evaluation, a good…
04:17Sorry.
04:18A good evolution, to put it bluntly.
04:21Very well.
04:22So I bounce back to the first question of why, because why do I think that the Economic
04:27and Social Council and the Environment Council were in, I would say, all these rights?
04:31Why?
04:32Because His Majesty the King, when he gave the speech in 2020 of the launch of what
04:37we call social protection, he gave, I would say, a very clear calendar.
04:41At the end of 2022, there must be…
04:43Sorry.
04:44At the end of…
04:45There you go.
04:46At the end of 2022, there must really be an acceleration of what we call social protection
04:49and that 22 million…
04:50Sorry, it's not 2022, but 22 million citizens can access what is called mandatory
04:55health insurance.
04:56So there, after a few, I would say, after 2020, we are now in 2024, after four years,
05:01a step-by-step report is imposed.
05:02And so there, it is legitimate for the Economic Council to enter its field of investigation.
05:06And it is clear in the beginning of the report, when he speaks, that we are evaluating a public
05:10policy and the Economic and Social Council, among its prerogatives, is to be able to
05:15give an opinion on public policies.
05:17And there, we are talking about a crucial public policy for Morocco, it is the health
05:21policy and the health coverage for all Moroccans.
05:24Especially with the crisis, after the crisis of 2020, which we experienced together, which
05:28in a way affected these health problems.
05:30Now, to answer your question, in relation to 31 million, if I take the balance sheet
05:36in a way, I would say, soft, in relation to what was asked, or I would say what was
05:42the objective of social protection or mandatory health insurance, we have reached a level
05:49that is really very saluted compared to the efforts that have been made by the government.
05:5431 million, so there, we have added about 14 million, we are not yet in the 22 million
06:00that have been projected, but 31 million, that is 87%, it is an achievement.
06:05But we have to salute the government in relation to that, that is to say, when we say it,
06:09that means there is a colossal effort that has been deployed by the government to be able
06:13to get to this point.
06:15The institutional effort, the legal effort, I find, it is an opinion of mine that is very
06:21objective, it is that the legal effort was there, that means we had a lot of texts.
06:26The budgetary effort too.
06:27Yes, I will come back to that.
06:28But I have classified, the first effort is the legal effort, all the legal texts are there.
06:32And all the institutional reform is there.
06:35We have a refund of what is called the health system.
06:37The budgetary effort was also there by the government and we have, I would say,
06:41figures that are very important.
06:43I will come back to the details of the billions that are deployed in this regime.
06:46Now, the problem, we have to be very objective, the problem no longer resides in the demand
06:52because the demand is already there.
06:54We have 31 million Moroccans who are unregistered.
06:57The problem that now resides is on the side of the offer, that is to say, the health offer
07:01does not yet meet the objective of what is called the universal health coverage.
07:06Because there is a whole debate, I think even the report of the Economic and Social Council
07:11comes back to this question of distinguishing, in a way, I would say,
07:15it plays with words in a very intelligent way,
07:17to distinguish between mandatory health insurance and universal health coverage.
07:21And so, all this debate between the two concepts, it allows a little to resume,
07:26I would say, the discussion on the way in which the regime of the word must be managed
07:30at the national level.
07:31And so there, we will have several findings.
07:33There are several findings here that need to be related and also highlighted
07:38in relation to an improvement in the future.
07:40What are the most striking, precisely, that particularly caught your attention,
07:44Zachariah Ferran?
07:45Very well.
07:46What caught my attention first is, in fact, we still have 8 million Moroccans
07:50who cannot benefit from what is called mandatory health insurance.
07:53This is an alarming figure.
07:55Despite the fact that we have realized the 31 million who are unregistered,
07:59in the 31 million, we still have 8 million who are outside the system.
08:03Why?
08:04These are technical reasons.
08:05First, we have populations whose rights have been closed.
08:08That means they are unregistered and they cannot access health services.
08:12And so there, it is a fundamental question in relation to the regime that has been put in place
08:17to be able to classify them.
08:19And I come back to that because it is a debate that needs to be had.
08:21It is that the choice that has been made in terms of mandatory health insurance in Morocco
08:25is a choice of classification by profession and by social-professional nature.
08:30And this choice may have to bounce today in terms of discussion
08:36to be able to find a reclassification, another way of seeing this classification.
08:41So, the classification by social-professional regimes
08:44gave us what we call people who are automatically excluded.
08:47In the Council, in the report of the Economic and Social Council,
08:50we are talking about 2.3 million beneficiaries who have the rights that are already closed.
08:55And so there, I am only talking about the CNSS.
08:57If we add those who belong to other regimes, we will arrive at more than 3 million.
09:01Automatically, we have other people.
09:04Closed rights, that means, for the viewers to understand,
09:07we are talking about people who cannot pay their fees.
09:11And so, automatically, they find themselves in what we call the exclusion of the system.
09:15Why the exclusion?
09:17Because we have chosen a regime based on a social-professional classification
09:21so that people understand what we are saying.
09:24The second element is that we have the Rolica.
09:26So, if I take the 8 million excluded from the system,
09:30who are outside the system, who cannot benefit, not to say excluded,
09:34we have the Rolica of about 4.8 to 5 million,
09:37so the Rolica between the two, 4.8 million, who are not registered.
09:41That means, until now, they do not have a regime that covers them.
09:44And there, the CNSS, they talk a little bit about what we call the women's aid.
09:49They also talk about some independents who are not in the regime, etc.
09:52These people, they have to find the solution so that they can join,
09:56enter what we call the system of mandatory health insurance.
10:01The second figure that caught my attention,
10:03excuse me for saying it, is that despite the budgetary effort
10:06that is made by the government, which is very commendable,
10:09which must be saluted, I would say,
10:12because these are funds that have really been put in place for the health system
10:17to have this mandatory health insurance coverage,
10:22we have a certain, I would not say failure,
10:24but a certain unlikeliness in relation to what is called
10:27the sharing of these resources between the private and the public.
10:30So we have about, if I may say so,
10:32more than 50% of these expenses in terms of mandatory health insurance
10:36that go to the private platform.
10:38That means for private clinics and private hospitals.
10:42So what raises the fundamental question is that the public sector
10:46is it sufficiently fit to accommodate the 31 million beneficiaries?
10:51And so that's why I said earlier,
10:53there is an effort that has been made,
10:55carried out in a very positive way on the demand,
10:58but on the supply, there is always effort to be made.
11:01Exactly. And what the CESE warns of in this opinion,
11:06is this imbalance, Professor Serimi,
11:09which could accentuate the inequalities of access
11:11and compromise the goal of universality.
11:14You are right to point it out,
11:16a policy is judged in two ways,
11:20either in relation to the objectives set out,
11:23the first approach,
11:24or a second approach in relation to the results obtained.
11:29We are faced with a situation where there are a number of objectives
11:33that have been set out by the government.
11:35It is a binding agenda
11:37that should have been the engine of this government policy.
11:43So it turns out that this government policy,
11:47which does not lack voluntarism, etc.,
11:50and goodwill,
11:51has not given the expected results
11:53since we have today an unequal situation
11:57with a hybrid system,
12:00since, as you have said and repeated,
12:02there were 8.5 million Moroccans who were excluded from the MOU,
12:06the mandatory medical insurance.
12:09What categories are they interested in?
12:12They are particularly interested in what are called
12:14the TNS, the non-employed workers.
12:16It is extremely important.
12:1865% of the non-employed workers are excluded.
12:23So we have to refine behind the 8 million,
12:268.3 million,
12:27we have to refine,
12:28it is the non-employed workers.
12:30Why was that said?
12:31Because either they did not pay their contributions,
12:35or they are facing complete administrative difficulties, etc.,
12:40or also due to a lack of government awareness
12:46to push these TNS, non-employed workers,
12:49to pay their contributions.
12:51You know, you have to be concrete.
12:54The contribution rights,
12:56it starts at 90 dirhams,
12:5990 dirhams, 100, 120, 150, etc.
13:02For non-employed workers,
13:05it takes 6 months of contributions,
13:07100 dirhams, 120 dirhams,
13:09it is money.
13:11It is money.
13:12Because these are budgets that are tight,
13:14you know,
13:15and so it is an expense,
13:17and it is not necessarily mobilizable.
13:19Do you think that for this,
13:21what is recommended,
13:22because we have 10 minutes left,
13:23we move on to the recommendations in this sense,
13:25moreover, of the CESE,
13:28it is to revise the rate of contributions in advance
13:31by removing the ceiling of contributions
13:33established at the level of the public sector?
13:35Or what are, in your opinion,
13:37what could be the solution?
13:39There is a track that you mentioned
13:42in the CESE recommendations,
13:44a first track,
13:45it says,
13:46you have to increase the contributions
13:49of high-income employees.
13:52Yes, because the charge is not the same
13:54when there are employees
13:56who have high incomes,
13:58from when there are high incomes,
14:00from 8,000, 10,000, 15,000, 20,000 dirhams.
14:03You know,
14:04the average salary of the public service in Morocco,
14:06you know how much it is?
14:07It's more than 9,000 dirhams,
14:08average salary.
14:09So there is a possibility, perhaps,
14:11to ask for an additional effort
14:13in this category.
14:15There is also the fact
14:17that a particular effort is needed
14:19if we want to push social policy to the end
14:22to help future taxpayers
14:25pay the sums due
14:27in terms of deductions,
14:29we will have to make an effort,
14:31it is a problem of equity,
14:32it is a problem of equity,
14:33it is also a problem of solidarity.
14:35I see that it is important
14:37that we do not leave 8 million people
14:40on the sidelines.
14:42So there is a need
14:44for national solidarity.
14:46Finally, one last point, perhaps,
14:49we have to review the current system.
14:53There are several regimes,
14:55there are several regimes that are mixed,
14:57that is to say that what the CESE proposes
14:59is a necessity,
15:00that is to say,
15:01the utilization of different existing regimes,
15:03also review the rates of reimbursement
15:06of medicines.
15:08You know, there are diseases that are taken,
15:11there is a nomenclature,
15:12and the nomenclature is not satisfactory,
15:15even because there is knobs,
15:17which is a nomenclature that goes up to more than 20 years,
15:20we go up to 2006 if I remember correctly.
15:22There are things that need to be reviewed.
15:24The five largest diseases
15:26posed to public health
15:29require the involvement of households
15:33which is important and unbearable.
15:35What are the five diseases?
15:36These are cancer, cardiovascular diseases, diabetes, etc.
15:39And so it is extremely important.
15:41And then there is the fact,
15:44on a social level,
15:46it must be noted that 50% of care
15:49is taken care of by households,
15:52while the standards of the WHO
15:54are 25%.
15:56And everyone knows in households,
15:58in Moroccan budgets,
15:59that there is an important share
16:01of buying medicines by households
16:03because there is not enough coverage
16:06or reimbursement.
16:08I also add to this, on a financial level,
16:10we have to worry,
16:12now that love is put in place,
16:14we have to worry about what is called
16:16the sustainability of the financial balance of love.
16:19This is a big problem.
16:21The government says it has committed,
16:25I have the figure,
16:27nearly 16 billion dirhams
16:29to support the regimes,
16:31like Lamothe, Adamonte, etc.
16:33It is an extremely important effort.
16:35For 2025, it is 22-24 billion dirhams.
16:39For 2026, it is more than 25 billion dirhams.
16:42It is an extremely important burden.
16:44So we will have to mobilize somewhere
16:46the budgetary resources on this subject,
16:48the problem of sustainability.
16:50We must not engage in a social system
16:53of social prevention
16:55that we cannot support because it would be a disaster.
16:58To avoid this,
17:02what caught my attention
17:04is that the Economic, Social and Environmental Council
17:07recommends reforms,
17:09legislative, regulatory and technical reforms,
17:11to make this disease insurance more accessible and effective.
17:14Should we review this model
17:17now that we are a little further along
17:21and above all, what are today,
17:24how do you see, Professor Ferranou,
17:28this system of governance,
17:30the system of mandatory medical coverage?
17:35Very well.
17:36To set the scene,
17:38the Economic, Social and Environmental Council
17:40was, I would say,
17:42normally, in its recommendations, it was clear.
17:45The first thing it indicated
17:47is that, first of all,
17:49the new authorities,
17:51I am talking here about the Health Authority,
17:53whose manager has just been appointed by His Majesty.
17:56It must start with what is called
17:58an impact study.
18:00What does an impact study mean?
18:01We must not forget that mandatory medical insurance
18:03is based on contributions.
18:05This is another debate.
18:06Earlier, I talked about what is called the choice,
18:08I would say, a little bit of the doctrine of insurance
18:11or universal health coverage.
18:13It is not found uniformly in all countries.
18:16For example, if you take England,
18:18if you look at the report,
18:19in England, it is really public.
18:21That means the action of universal health coverage
18:23and the measures taken by the state.
18:25That means there are no contributions.
18:27Automatically, it is a minimum
18:29of what is called a health coverage
18:31that is recommended for all citizens.
18:33And it is not only in England,
18:35in several countries.
18:36There is a minimum.
18:37There is a minimum.
18:38It is a care package.
18:39That's it.
18:40You have to specify.
18:41Yes, I specified.
18:42It is a care package.
18:43I insist on that.
18:44This care package, which is a minimum,
18:46which will allow Moroccan citizens
18:49and all the citizens of the planet,
18:50because universal health coverage
18:52is a universal problem.
18:53It is for the whole planet.
18:54The goal is not to fall into precariousness
18:57because of health.
18:58And that is very important.
19:00We, in our logic now,
19:01the contribution and being in a situation
19:04of amour-tadamon,
19:05it is a question of whether you have
19:07a social professional status or not.
19:09And we forget the fundamental question.
19:11It is that universal health coverage,
19:13you can be very rich and become very poor
19:15because of a health problem.
19:17And so, it is not a question
19:18of social professional classification.
19:20And it is a deep debate.
19:21Now, the economic council,
19:22and we have to come back to this debate,
19:23that's why the economic and social council,
19:25they talk about impact studies.
19:26And excuse me, I will say it in a way,
19:28well, it was said clearly,
19:30but according to the sayings of what we call
19:32the economic and social council,
19:34there was no impact study.
19:35And so, here, we are talking about
19:37a regime of transfer of funds.
19:39Be careful.
19:40The amour, or what we call the regimes of quotations,
19:42these are regimes of distribution of wealth.
19:44It allows the transfer of funds
19:46within the economy.
19:47And so, these types of regimes,
19:48you have to have an impact study,
19:49what we call micro-simulation studies,
19:51to see the impact on social classes,
19:53on income,
19:54and also on all macroeconomic aggregates.
19:56Until now, this has not been done.
19:58This is the opportunity.
19:59We now have the high health authority
20:02that will be able to do this work
20:05to be able to frame
20:07if there are insufficiencies in this regime.
20:09Now, currently, what do we have?
20:11First, we have problems
20:12that need to be solved quickly.
20:14We have problems of inequality.
20:15You raised them earlier.
20:16Inequality, not only in terms of income
20:18or social-professional class.
20:20Territorial inequalities.
20:21Yes, territorial inequalities.
20:23You know that it has been said,
20:25it's not me who says it,
20:2667% of what we call the health care platform,
20:28hospitals, are in five regions.
20:30The other regions do not have the potential
20:33to be able to offer
20:34what we call health care.
20:36Secondly, and a very important element,
20:38is that today you have the CNSS
20:40which is climbing in terms of files,
20:43governance, management,
20:45and this will affect, at some point,
20:47the ability to manage
20:48and the ability to govern.
20:50We also have another problem
20:52which is very important
20:53and which will have to be taken
20:54with a certain, I would say,
20:56a certain rigor or prudence.
20:59It is, in fact, disparities or equity
21:01in terms of health care.
21:02Until now,
21:03we have different cost rates,
21:05different health plans,
21:07and also different platforms.
21:09For example,
21:10you mentioned that in Lamo,
21:12you have the CNOPS which is 5%
21:14with a ceiling of 810 rams.
21:16The other, we don't have a ceiling.
21:18Now, if we change the configuration,
21:20it will be really, I would say,
21:22it will be additional sums
21:23that must be paid for,
21:24I would say, for the officials
21:25or those who work at the level,
21:26or those who belong to what we call
21:27the CNOPS regime.
21:29There is also a very important element
21:30that we have forgotten.
21:31What is it?
21:32It is that we need a health care offer.
21:34Where are the hospitals
21:35which are, which are part of the CNOPS
21:37and which are part of the CNSS?
21:39They have not yet been activated.
21:41And that would improve
21:42what we call health care.
21:43Here is the health care offer.
21:45And so, in all these elements,
21:47with the elements of,
21:49you mentioned, which is very important,
21:50what we call the out-of-pocket,
21:52you have 50% of what we call the costs
21:54without paying for the housing.
21:56And here, what is interesting
21:57in the Council report,
21:58is that why do we pay them?
22:00That means, why are they not paid?
22:01Even if you are in a regime
22:03amo ta damone.
22:04And so, here,
22:05it comes back to what we call
22:06the problems of perception,
22:08the problems of hospital management,
22:10the problems that are also linked
22:12to the experiences of what we call
22:14the beneficiaries in the hospitals.
22:16And here, in all these problems,
22:18I think they are linked
22:19to what we call the health care offer.
22:21We need to make a very colossal effort
22:23on the part of the offer,
22:24because the part of the demand,
22:25we have done, we have saluted
22:27the efforts that have been made
22:28by the government
22:29in terms of legislation,
22:30in terms of budget,
22:31in terms of accessibility,
22:33but there are now problems
22:35that come from what we call
22:36the negative externalities
22:38of the health care regimes
22:39based on a socio-professional categorization.
22:42It is also interesting to note
22:44that 95% of the affiliates
22:47consult in the private sector.
22:49Yes, that's what I said earlier.
22:51No, but it's still a very alarming figure.
22:56And there are 33 billion people
22:58who have paid for it,
22:59who are going to the private sector,
23:00at 90%.
23:01At 90%.
23:02That's the problem I wanted to ask.
23:04First of all, you were right to raise the issue.
23:06Beyond the offer
23:08that is made by the government
23:10and of this product,
23:11which is the AMO,
23:13which is an acquisition,
23:14of course, we must congratulate it,
23:16there is a problem of governance,
23:17governance of a health policy.
23:19We must not limit ourselves
23:21simply to the management
23:23of the different regimes.
23:24We must go beyond,
23:25unify, standardize, etc.
23:27There is another problem
23:29that benefits from the important funds
23:33that are eligible
23:35for the management of the AMO.
23:37There is the public sector,
23:38there is the private sector.
23:39It turns out,
23:40nevertheless, it must be said,
23:42that 95% of the AMO affiliates
23:47consult in the private sector.
23:50I add that more than 80%
23:53of the insurance companies of the CNOPS
23:55also consult in the private sector.
23:58In short, employees, employees.
24:00Yes, and even 57% of the AMO affiliates.
24:05What does that mean?
24:07It means that we have a social policy
24:10that must be saluted,
24:11that must be supported, etc.,
24:13but which leads to,
24:15in its application,
24:17to the distance
24:20and the gap
24:22between the private sector and the public sector.
24:24It is not the public sector that benefits from this.
24:27It is the private sector.
24:29This is a choice of health policy
24:31that must be resolved
24:32because, in the end,
24:33the public sector cannot level itself
24:36and offer a wide range of care.
24:39It is the clinics of the private sector
24:43that benefit from this social policy
24:45and this is something that must be reshaped.
24:47Quickly, in two words,
24:49to close the debate,
24:50the showtime is almost over.
24:52Gentlemen,
24:53now that this report has been issued
24:55and therefore a state assessment by the ECE,
24:57what do we do with it?
24:59In terms of public policy.
25:00We need national seats.
25:01In two words,
25:02we need national seats
25:04and a debate on health policy
25:07from this report.
25:09We cannot classify this report
25:10and say that there is nothing at all.
25:12Knowing that it is not the Parliament
25:13that has seized the Council.
25:15It is a self-seize of the Economic Council.
25:17I remind you.
25:18The first element is that
25:19I just want to point out
25:20an element that is also very important.
25:22The problems of the deficit
25:23that have been raised in the Council report
25:26also relate to the problem of drugs.
25:28We haven't talked about it,
25:29but it poses a huge problem.
25:30It is three to four times more expensive
25:32than in neighboring countries.
25:34For some drugs.
25:35For some drugs.
25:36And it is a problem that is partly
25:38the problem of the deficit.
25:40Now, what needs to be done,
25:42I think that the roadmap has been put in place.
25:47I think we need to start with impact studies.
25:49This is very important.
25:50Very good.
25:51A re-framing of politics
25:52if there are deficiencies
25:53in relation to the issue of supply.
25:55And thirdly,
25:56sincerely think about
25:58what is an equity
25:59and a sustainability of this regime.
26:02Thank you very much.
26:04Thank you, Professor Felanon.
26:05Thank you, Professor Samir.
26:07Always a pleasure.
26:08This is the end of this episode of Questions d'Actu.
26:09Have a very good evening.