Constraints and obstacles to social health protection in the Maghreb: the cases of Algeria and Morocco

Abstract

Introduction Economic variables must be taken into account in any attempt to develop social health protection systems. However, such variables should not blind us to the importance of social protection as a civic right and as an effective way to improve the well-being of the population, with a resulting positive effect on the economy. Building or reforming social health protection systems involves a complex combination of political, social and technical factors and strategies. Reforms often call for major changes in resource allocation and in the distribution of power and thus evoke fear and resistance among small but powerful segments of society. This paper briefly describes attempts made by Morocco and Algeria to reform their social health protection systems. Evolution of social health protection systems The measures taken in Morocco to reform social health protection spanned the period from 2002 to 2006. Before 2002, several coexisting optional health insurance schemes covered only 17% of the population. A system of certificates of indigence was operating in parallel and still exists today. Individuals who consider themselves indigent may submit a request to local authorities to receive a certificate granting them access to subsidized hospital care in public facilities. Such a system is universally criticized for being plagued by serious malfunction. (1) In 2002, after several abortive attempts at reform, the Youssoufi government (1997-2002) pushed through a framework law (No. 65-00) on basic medical aimed at phasing in universal coverage for the Moroccan population. This law has two components: compulsory health insurance (Assurance maladie obligatoire, AMO) and medical care (Regime d'assistance medicale, RAMED) for persons in need. While the initial decrees on AMO, which were passed in 2005, only concerned the formal sector, in 2007 the Jettou government (2002-2007) extended coverage to self-employed professionals outside the AMO, through a plan known as Inaya. The RAMED, under pilot-testing in one province, had not yet come into being. With independence in 1962, Algeria inherited a fragmented social protection system with disparities in the population and services covered. Beginning in 1970, the government implemented a series of measures to harmonize and unify social protection schemes. Major health programmes were launched, and the decision to provide public sector health care for free was made in 1974. By 1983 this trend had been consolidated through the unification of social security plans. The nationalization of natural resources, the growth of oil revenues and the launch of a vast movement to industrialize the economy and pay fair salaries to the economically active population provided the foundations for the extension of social protection. This top-down way of building a broadened social protection system and health insurance plan was relatively successful for as long as the central government had substantial financial resources and continued to rapidly develop salaried employment in the public sector. The system covered almost all risks (disease, maternity, disability, death, retirement, work injuries, unemployment, etc.) for more than 85% of the population. In 1988, however, oil revenues slumped, marking the end of the social consensus based on the redistribution of income. This ushered in a protracted and exceptionally violent political, economic and social crisis. Economic constraints for Morocco Despite an annual increase of more than 4% in its per capita gross domestic product over the last decade, Morocco's economic status remains modest, with an annual per capita income still less than 2000 US dollars. Moreover, this economic growth has not significantly reduced the unemployment rate, which is 16% in urban areas, or the poverty level, with 15% of the population being poor and 23% economically vulnerable. …