Bartering with your health

Bartering with your health

For hundreds of years, Morocco’s geographical location at the entrance to the Mediterranean Sea has allowed it to serve as one of the main trading channels between Europe and Africa as well as a prime tourist destination. Now, a surge in medical tourism looks set to test Morocco’s health facilities to their limit. Robert Bailey investigates further

First published in ITIJ 104, September 2009

For hundreds of years, Morocco’s geographical location at the entrance to the Mediterranean Sea has allowed it to serve as one of the main trading channels between Europe and Africa as well as a prime tourist destination. Now, a surge in medical tourism looks set to test Morocco’s health facilities to their limit. Robert Bailey investigates further

Morocco’s draw as an exotic vacation destination, complete with its historic cities, alluring beaches, mountains and deserts and rich historical and cultural tapestry, is rapidly attracting more international tourist traffic, as well as millions of French tourists, including Moroccans living in France, who arrive during the summer months. Skilled marketing campaigns presenting the country as both a cultural heritage and activities destination have also stimulated substantial numbers of arrivals from the rest of Europe. Relatively short air travel times from Western Europe mean that Morocco has become an increasingly popular destination for French, Spanish, Belgian, Italian, Dutch, German and British visitors in particular.

According to Morocco’s Ministry of Tourism, there were around 419,000 UK tourist arrivals in 2007. Consequently, the number of visitors to the country has more than trebled over the last 25 years with nearly 7.5 million tourists in 2008. More recently real estate development has also started to draw in longer-term foreign residents buying holiday homes and retirement properties.

Routes through the Rif and Atlas mountains [are] steep, narrow, winding and, for the most part, dangerous

This sudden influx has resulted in the income derived from tourism becoming a crucial element in Morocco’s economy. Annual receipts over the last few years have averaged $7.5 billion, ranking second only in importance to the country’s phosphate exports. The country’s tourism industry is now poised to expand even further over the next few years as a result of the Government’s Vision 2010 development aims and Plan Azur. This strategy seeks to create six new coastal resorts and hundreds of new hotels in an effort to accommodate up to 12 million visitors by 2012. However, there will be costs associated with such rapid change. How far the country’s infrastructure and services, notably health care, will keep pace with an increase in holiday visitors and the arrival of longer-term residents buying resort properties is an open question.

Healthcare provision

The state of the Morocco’s medical facilities varies considerably, with a creaking and chronically under–resourced public health sector juxtaposed with privately owned and managed hospitals and clinics. In urban areas, the latter offer adequate services for visitors, at least for the time being, but a growing pressure on services is likely to become more apparent if Morocco’s targeted increase in visitor numbers materialises.

This may be seen not only in the availability and quality of medical care and facilities, but in more basic ways. Visitors should be aware that most medical staff have limited or no foreign language skills, particularly in public hospitals. According to Dr Franck Lacord, medical director of France’s Inter Mutuelles Assistance, some doctors in the country’s university hospitals, although not the majority, will speak English. He cautions, though, that one should not expect to find English speaking doctors or nurses outside the country’s main cities.

Nevertheless, Thierry Montrieux, provider network manager for Healix, considers that healthcare services in major cities and some private clinics in Morocco are acceptable and provide western standards of care. Some major hotels also provide ‘doctors on call’ services. However, not all facilities meet high-quality international standards and specialised care and treatments may not be available. Outside of the main cities, medical services and facilities would be considered below western standards, he says. University hospitals are located in Morocco’s main cities, such as Rabat and Casablanca, the most recent being the new university hospital in Marrakech. Teaching hospitals tend to be better equipped with a wider range of specialist units when compared to other public hospitals. Private facilities, according to Dr Lacord, have a wider range of specialties– found in hospitals such as Clinque dar Salam in Casablanca and Clinique Aqbal in Rabat. In fact, Lacord’s view is that Morocco’s public hospitals simply are not suitable for foreign patients but “there are a lot of private medical facilities able to take care of the usual pathologies.” He points out as well that nursing standards vary and, for Moroccans who are ill in hospital, family members are usually present.

Reports indicate that 18 per cent of the population does not have direct access to drinking water and 25 per cent of the rural population is located more than 10 kilometres from the nearest health facility

Visitors to larger urban areas are able to access help for non-emergencies, although relatively few staff, including doctors, are likely to speak English, except in some of the major private clinics. If visitors and their families lack language skills, the need to have someone to translate properly could be vital for correct diagnosis and treatment. For most travellers, though, any problems that crop up will be mostly minor and easily and effectively treated – diarrhoea is still the most common travel-related ailment likely to occur. Everyday prescribed items and over-the-counter medicines are also available in Moroccan cities, but some of the newer prescription medications may be difficult to obtain – it may be extremely difficult to obtain medications of any kind in rural areas. ‘Be fit and stock up on any drugs that may be needed before travelling’ is the basic advice for all travellers. Depending on which parts of Morocco a visitor is intending to travel to, national advisory notices often recommend hepatitis A and hepatitis B vaccinations. A tetanus diphtheria vaccine is also recommended for those not immunised in the last 10 years and for all travellers over the age of one, as well typhoid for those over six years of age. However, anyone embarking on lengthy trips in rural areas in addition is advised to carry a medical kit as well as a Moroccan phone card for emergencies.

On the road

Probably the most serious potential hazard for visitors, particularly the growing numbers beginning to explore the hinterland and mountains of Morocco by foot, cycling or car, is presented by the country’s roads. The main problem, Dr Lacord says, is the quality of the country’s highways and the distances between towns and cities where medical and ambulance services may not be available at all. Accident figures have been on the rise in Morocco for several years, mainly due to greater traffic but also poor driving skills and safety enforcement compared to European or US standards. Car drivers also have to contend with trucks and tankers, scooters and animal-drawn conveyances, and pedestrians can be seen on all roads, even motorways. While modern freeways connect the cities of Tangier, Rabat, Fez, Casablanca and Marrakech and two-lane highways link other large cities, the secondary routes in rural areas are often narrow and poorly paved, with routes through the Rif and Atlas mountains steep, narrow, winding and, for the most part, dangerous.

Reported road traffic accidents average nearly 60,000 a year, including a significant percentage of seriously injured and fatalities. The level of accidents also rises at night due to poor lighting and inadequate traffic signals. There are lots of overloaded trucks, ‘crazy bus drivers’ motorcycles and carts without any lights. Dr Lacord’s advice is “never drive at night; be careful; nobody can help if there is serious injury.”

It is not unknown for pharmacies to supply out-of-date medicines and counterfeit medication has also been known to be an issue

The difficulties of driving in Morocco are compounded during the month of Ramadan, especially at dusk as fasting ends and adherence to traffic regulations tends to become even more lax. The summer months from July to September when hundreds of thousands of expatriate Moroccans return home by car is also a time when the number of collisions and serious accidents rises sharply. Maximum caution is also needed when driving in rural areas during the rainy season between November and March when flash floods are a frequent occurrence. If injuries are sustained, the help and services available are very much dependent on location. Major cities are relatively well serviced, although the quality of ambulances and standard of equipment varies and cannot always be relied on. Montrieux also cautions “blood supplies are not considered safe as they are poorly regulated.” However, Lacord believes that Morocco has made great improvements with blood donation – donors are not paid and the level of AIDS is low. He points out: “Blood is safer in the Mghreb than in Africa.”

Public health

However, if medical services for visitors are inconsistent, health conditions for the bulk of the population, especially people living in rural areas, are much worse, even when compared to other countries in the region. Emergency departments are often inefficient due to a lack of equipment and inadequate levels of nursing care. Consistency of emergency care depends a great deal on the medical staff and the treatment available at different hospitals, all of which varies greatly – again, university hospitals can cope better than those in the public arena. Morocco’s per capita expenditure on medical goods and services for many years has lagged behind that of most other countries in the region such as Lebanon and Jordan, as well as Tunisia where public expenditure accounts for more than 75 per cent of the total spent on health care. General government expenditure on health forms only 39 per cent of Morocco’s total health expenditure – the rest is privately funded. The situation in Morocco is made more complicated because most households do not have access to medical insurance or mutual schemes. Morocco also suffers from a substantial deficit in terms of qualified human capital in the medical and related fields, with many of the country’s trained doctors opting to work abroad in countries such as France and Belgium where their earning potential is far greater than at home. The public basic healthcare network comprises about 2,500 health facilities supplying curative and preventive healthcare services and providing about 25,000 beds in total.

Not all hospitals and clinics are maintained to adequate standards and often lack capacity. The number of beds has to meet the needs of some six million patients seeking care each year, half of them emergency cases. Morocco’s public health expenditure tends also to be concentrated on city areas, with nearly 80 per cent of expenditure going to urban hospitals and clinics. In addition, most doctors are concentrated in the cities with the rural population most vulnerable due to the lack of facilities and medical staff. This means that many rural areas are left with meagre facilities and a lack of doctors as well as nurses and midwives.

The World Health Organisation (WHO) listed Morocco as having 15,991 physicians in 2004, providing a density of 5.3 doctors per 10,000 of population, with most doctors as well as dentists concentrated in Casablanca and Rabat. While the proportion of specialists in Morocco is average for North Africa, there is a severe shortage of gynaecologists, obstetricians, anaesthetists and nephrologists and other consultants. For most Moroccans, proper health care is, in any event, largely beyond their means. A minority of the population is covered by private insurance, which covers the employees of some 3,000 firms. These account for just over 18 per cent of the country‘s medical insurance beneficiaries. In-house schemes are provided by some public companies and corporations.

Financing

Collective financing of health expenses is optional and very limited covering barely 16 per cent of people and embracing mainly civil servants and workers in the urban formal sector of the economy. Some 54 per cent of the country’s health expenditure is accounted for by direct payments by households, including those reimbursed by insurance companies. Morocco is a predominately agrarian country comprising of large families with small incomes. Many people living and working in the cities are not registered workers and live hand-to-mouth in the ‘informal sector’ of the economy. Minor ailments can be treated relatively easily, but complications requiring surgery, lengthy diagnostic investigation and treatments can be financially ruinous. Several institutions provide health insurance. The main ones are Caisse Nationale des Organismes de Prevoyance Sociale (CNOPS) covering employees of the armed forces, auxiliary forces, postal workers, police, port authority, customs as well as civil servants and those employed local authorities and teachers. But CNOPS still only covers half the cost of insured services. There is also Morocco’s inter-professional mutual fund (CMIM), which covers the employees of some 250 firms in the banking and hydrocarbons sectors. For most ordinary Moroccan citizens though health care is considered poor by western standards.

The situation is even more severe outside the cities. The WHO reports indicate that 18 per cent of the population does not have direct access to drinking water and 25 per cent of the rural population is located more than 10 kilometres from the nearest health facility while 35 per cent of Moroccans do not have access to essential drugs. In spite of these poor indicators, programmes of mass education in child and parent hygiene, as well as government-supervised health services in schools and colleges have helped to raise standards in recent years. However, other health problems still persist in some areas of the country, including gastrointestinal infections, malaria, typhoid, trachoma and tuberculosis.

While there are no dedicated air ambulance services, there are some companies able to provide private air services using Citation, Falcon 10 and King Air 200 planes

When compared to other countries with similar income, Morocco, in spite of the weakness of its health system, has in the past allocated less to health. However, after decades of prevarication, Morocco officially launched its long-discussed medical assistance regime (RAMED) in 2005, which aims to provide healthcare coverage to Moroccans not covered under employer-based mandatory health insurance programmes and other insurance cover. The first stage of the project aimed to increase coverage of the registered employee population from 17 per cent to 34 per cent, reaching more than 10 million people. A second stage of the scheme extends health insurance coverage to the self employed which will increase coverage to around 50 per cent of the population. A big problem for the country’s administration of the public health care system has been its centralisation, which has made regulation and co-ordination of health services managerially cumbersome. Current strategy now focuses on restructuring the system to provide more regional centres and also decentralise management of health care facilities.

Moving forward

Morocco’s Health Minister Yasmina Baddou also announced a new four-year plan in 2008 designed to bring down the cost of health care and medicines, as well as make treatments more accessible to less privileged members of Moroccan society. Ridding public hospitals of corruption is another major component of the plan. A system for victims to file formal complaint is being set up in partnership with Transparency Maroc – an organisation set up by a group of Moroccan citizens in 1996 with funding from the Netherlands embassy in Morocco with links to Transparency National, Berlin, which monitors global corruption. Some argue that video cameras should be standard in hospitals and doctors and nurses who demand bribes to allow patients to be seen should be criminally prosecuted. Officials who turn a blind eye to abuses should also be made accountable. But few visitors are likely to be directed to public hospitals if private clinics are available, even though there is no obvious choice of private care for those requiring treatment. Advice is best provided by an individual’s insurance provider or consular service. The US consulate in Casablanca, for example, lists three 24-hour emergency private clinics in the city – Clinique Badr, Clinique Yasmine and Clinique Zerktouni. 

Health at what cost?

Referrals and admissions to hospitals are dependent on the circumstances. For example, hotels typically direct policyholders to hospitals they have relationships with, while assistance providers have access to local agents who will arrange an admission on behalf of the insurer for a fee of around $150. Most doctors and hospitals, in addition, will expect payment in cash, regardless of whether a traveller possesses travel health insurance. “Private clinics will accept credit cards as a form of payment but visitors will still be expected to pay cash outside of the major cities,” according to Healix’s Montrieux. IMA’s Lacord concurs: “Usually cash will be expected but some private clinics in the major towns will accept credit cards.” In overall terms, Lacord’s view is that costs are usually reasonable and close to levels in Tunisia and cheaper than in Turkey, Spain and Greece. According to Montrieux the cost of treatments is considered generally similar to charges throughout the Mediterranean, although there is a propensity for excessive charging given the opportunity. “It is not unknown for pharmacies to supply out-of-date medicines and counterfeit medication has also been known to be an issue. To our knowledge, and from extensive research, medical charges are not subject to any regulation,” he says.  “The private sector is very good at billing processes. However, payment collection is aggressive resulting in situations where a discharged patient will only be released after payment is received. Unfortunately billing accuracy is sometimes suspect with unnecessary charges for medicines a commonplace occurrence,” he observes. Lacord comments that medical charges for foreigners are normally higher than those for Moroccans and for surgical procedures, pricing is based on what would be levied in France.

Outside the major cities the picture is very different with an emphasis placed on availability of services rather than choice and cost, since medical care may be difficult or impossible to find in some areas. As a result, the most serious problems may well require air evacuation to a country with necessary medical facilities. Airlift will require logistical co-ordination with an external provider since there are no local companies offering air ambulance services. This is something of an irony given that the first such civil evacuation services were pioneered in Morocco in 1934 by the legendary French aviation pioneer Marie Marvingt. While there are no dedicated air ambulance services, there are some companies able to provide private air services using Citation, Falcon 10 and King Air 200 planes, Lacord says. He also comments that, in a serious case involving a tourist, the patient would normally be taken to a military hospital – to prevent reputational damage to the country as well for humanitarian reasons. However, dedicated medair providers are also based in Spain, France and other nearby countries, all within a short flying time away – these can access more than 25 civil airports throughout Morocco.

"Morocco’s public health expenditure tends also to be concentrated on city areas, with nearly 80 per cent of expenditure going to urban hospitals and clinics"

Irrespective of extreme emergencies, as well as weaknesses in a number of aspects of its healthcare facilities both private and public, the raising of standards in Morocco seems to be much more of a priority for the country than in the past. The Government is said to be aware of the value of working with the private sector to bring about improvements in future health care and to create a favourable environment to improve the health sector. Healthcare coverage by the private sector, although often limited to urban areas and large cities, still covers two-thirds of primary health care services and 20 per cent of the national bed capacity. Morocco has more than 269 private clinics providing about 5,500 beds. Half of this capacity is located in Casablanca and the remainder distributed between Rabat, Marrakech, Agador and Fez and other principal cities. But the health sector traditionally has not been an area open to foreign direct investment. Even Moroccan physicians working abroad cannot invest in private clinics unless they return and register exclusively in Morocco. However, given the capacity and funding limitations of the state healthcare system it seems inevitable that as tourism expands the development of health care in Morocco will focus on an expanded role for the private sector.