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AFRICAN DEVELOPMENT BANK
MEDICAL COVERAGE REFORM SUPPORT PROGRAMME - PHASE 3
(PARCOUM III)
COUNTRY
:
Kingdom of Morocco
APPRAISAL REPORT
OSHD DEPARTMENT
December 2013
Translated Document
TABLE OF CONTENTS
ACRONYMS AND ABBREVIATIONS...........................................................................................
LOAN AND GRANT INFORMATION..............................................................................................
PROGRAMME EXECUTIVE SUMMARY.........................................................................................
RESULTS-BASED LOGICAL FRAMEWORK...................................................................................
1.
2.
ii
iii
iv
v
1
2
2.3
2.4
PROPOSAL............................................................................................................................
COUNTRY AND PROGRAMME CONTEXT..................................................................
Government’s Overall Development Strategy and Medium-term Reform
Priorities.........................................................................................................................
Recent Economic and Social Developments, Outlook, Constraints and
Challenges......................................................................................................................
Sector and Related National Programmes..............................................................................
Bank Group Portfolio Status...................................................................................................
3.
3.1
3.2
3.3
3.4
3.5
3.6
RATIONALE, KEY DESIGN ELEMENTS, AND SUSTAINABILITY........................
Linkage with the CSP, Country Readiness Assessment and Analytical Bases......................
Collaboration and Coordination with Other Donors...............................................................
Outcomes and Lessons Learned from Similar Past and Ongoing Operations..................
Linkage with Bank Ongoing Operations............................................................................
The Bank’s Value Added and Comparative Advantage........................................................
Application of Principles of Optimal Conditionality Practices...........................................
7
7
8
8
9
9
10
4.
4.1
4.2
4.3
4.4
4.5
4.6
4.7
PROPOSED PROGRAMME.......................................................................................
Programme Goal and Objective......................................................................................
Programme Components, Operational Policy Objectives and Expected Outcomes.............
Implementation Status of Programme Reforms....................................................................
Financial Requirements and Financing Arrangements.....................................................
Programme Beneficiaries...............................................................................................
Programme Impact on Gender........................................................................................
Environment and Climate Change.................................................................................
10
10
10
15
16
17
17
17
5.
5.1
5.2
PROGRAMME IMPLEMENTATION, MONITORING AND EVALUATION..........
Implementation Arrangements.......................................................................................
Monitoring and Evaluation Arrangements.....................................................................
18
18
19
6.
6.1
6.2
6.3
LEGAL DOCUMENT AND AUTHORITY...............................................................
Legal Document..........................................................................................................
Conditions for Bank Intervention................................................................................
Compliance with Bank Group Policies........................................................................
20
20
20
20
7.
RISK MANAGEMENT
21
8.
RECOMMENDATION
21
2.1
2.2
2
2
6
6
List of Figures
Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6
Figure 7
Budget Index Trends (1997-2010)
The Richest Quintile Owns About Half of the Country’s Wealth, 2007
Infant Mortality in Morocco Remains High
Malnutrition (Moderate or Severe) is Higher Among Rural Children
Level of Registration in RAMED Varies from One Region to Another, 2013
Direct Household Payments Account for More Than 50% of Total Health
Expenditure
Public Health Expenditure Account for Only One-Third of Total Health
Expenditure
p. 3
p. 3
p. 4
p. 4
p. 5
p. 5
p. 5
List of Tables
Table 1
Table 2
Table 3
Table 4
Table 5
Table 6
Morocco: Key Macro-economic Indicators (2010-2018)
p. 2
The Most Remote Regions Have the Highest Poverty Rates
p. 3
Conditions Precedent to Sector Budget Support
p. 7
Reform Measures that will Trigger Disbursement
p.16
Estimated Budget Balance and Financing Requirements 2012-2015 (in
MAD billion)
p.16
Risks and Mitigation Measures
p. 21
List of Appendices
Appendix 1
Appendix 2
Development Policy Letter
Matrix of Medical Coverage Support Programme – Phase 3 Reform
Measures
Appendix 3
Appendix 4
IMF Press Release
Recent Key Economic Indicator Trends and Projections, 2010-18
Currency Equivalents (May 2013)
UA 1
UA 1
=
=
MAD 12.84
EUR 1.15
Fiscal Year
1 January - 31 December
Government’s preferred currency of disbursement
EUR
i
ACRONYMS AND ABBREVIATIONS
AECID
ADB
AFD
ANAM
BMC
CHI
CNOPS
CNS
CNSS
CSP
DHSA
EIB
EU
FCS
FDI
HCP
IGM
IMF
INDH
LOF
MDG
MEF
MIC Grant
PAAFE
PADESFI
PARAP
PARCOUM
PARGEF
PAS Santé
PSO
RAMED
SGG
TFP
UNFPA
WB
WHO
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
Spanish Agency for International Development Cooperation
African Development Bank
French Development Agency
National Health Insurance Agency
Basic Medical Coverage
Compulsory Health Insurance
National Fund for Social Security Agencies
National Health Accounts
National Social Security Fund
Country Strategy Paper
Directorate of Hospitals and Outpatient Care
European Investment Bank
European Union
Social Cohesion Support Fund
Foreign Direct Investment
High Commission for Planning
General Inspectorate of Ministries
International Monetary Fund
National Human Development Initiative
Organic Finance Law
Millennium Development Goal
Ministry of the Economy and Finance
Middle-Income Country Grant
Training-Employment Matching Support Programme
Financial Sector Development Support Programme
Public Administration Reform Support Programme
Medical Coverage Reform Support Programme
Economic and Financial Governance Support Programme
Health Sector Reform Support Programme
Programme Support Operation
Medical Assistance Scheme for the Economically Disadvantaged
Secretariat General for the Government
Technical and Financial Partner
United Nations Fund for Population Activities
World Bank
World Health Organization
ii
LOAN AND GRANT INFORMATION
Client Information
BORROWER:
KINGDOM OF MOROCCO
EXECUTING AGENCY:
Ministry of the Economy and Finance
(Department of the Budget)
Financing Plan
Source of Financing
ADB
European Union
Amount
EUR 115 M
EUR 50 M
Instrument
ADB Loan
Grant
Information on ADB Financing
Loan currency
Type of interest rate
Base rate (floating)
Loan margin
Cost of borrowing margin
(CBM)
Commitment charge
Other charges
Duration
Grace period
EUR
Floating base rate with a fixed rate option
6 months - EURIBOR
60 basis points (bps)
Half-yearly weighted average of the difference between:
(i) the Bank’s refinancing rate on loans indexed on six (6)
months EURIBOR, and (ii) EURIBOR. The CBM will
be calculated on 1 January and 1 July.
In the event of a disbursement lag with respect to the
disbursement schedule specified in the loan agreement, a
25 basis point per annum charge will be applied to the
undisbursed amounts. It will increase by 25 basis points
every six months, up to a limit of 75 basis points per
annum.
None
20 years maximum
5 years maximum
___________________________________________________________________________
1.
2.
3.
4.
5.
6.
7.
8.
Activities
Preparation Mission
Concept Note Approval
Appraisal Mission
Loan Negotiation
Board Presentation
Effectiveness
First Disbursement
Second Disbursement
9.
Supervision
Date
28 January to 9 February 2013
4 April 2013
8 to 19 April 2013
July 2013
October 2013
November 2013
January 2014
December 2014
January 2014
May 2014
October 2014
June 2014 and June 2015
June 2015
10. Audit of Financial Flows
11. Completion Report
iii
PROGRAMME EXECUTIVE SUMMARY
Programme
Overview
Programme
Outcomes
Needs Assessment
Bank’s Value
Added
Institution and
Knowledge
Building
The Medical Coverage Reform Support Programme Phase III in Morocco is a Reform Support
Operation (RSO) designed as a UA 100 million sector budget support loan to the Ministry of
Health, disbursable in two tranches, to improve social protection and medical coverage for
Moroccan citizens. It supports the implementation of the Bank’s Strategy for 2013-2022 and
the CSP by focusing on inclusive growth and supporting the implementation of social
protection programmes. It will help to establish mechanisms needed to pilot and finance the
reform, enhance social protection coverage for the population, and contribute to providing
appropriate and quality services. This programme will be implemented within a context of
political and macro-economic stability, moderate fiduciary risk and Government’s firm
commitment to the implementation of the medical coverage reform and the generalization of
the Medical Assistance Scheme for the Economically Disadvantaged (RAMED) in line with
previous PARCOUMs. The programme was designed by the Government with the support of
the European Union.
In general, social protection programmes “cushion economic and social shocks, thus enabling
social outcasts and vulnerable people to benefit from broad economic opportunities” (Bank’s
Strategy for 2013-2022). The specific objective of this programme is to improve social
protection and medical coverage for the Moroccan population, particularly the most vulnerable
segments, by extending basic medical coverage and improving access to quality health
services. This programme seeks to improve physical and financial access to health services and
quality social services. The programme should help to increase the proportion of the population
covered by a social protection scheme (from 49% to 60%), reduce the share of direct payments
in health expenses (from 53% to 48%), and improve the perception of the quality of health care
delivery (from 23% to 40%).
The Moroccan Government has, since 2005, embarked on major social projects, including the
National Human Development Initiative (INDH) which supports income-generating activities
and RAMED. However, only 30% of the Moroccan population is satisfied with the manner in
which the Government is providing assistance to the poor, compared to more than double this
percentage in Tunisia and Jordan. In Morocco, more than half of the population (51%) does
not benefit from social protection. Health expenses remain a burden for Moroccan households,
exposing them to the risk of impoverishment due to illness. In fact, households bear more than
half of total health expenses (53.6%).
Morocco intends to improve access to basic social services for its population by developing
social protection mechanisms. Indeed, RAMED and basic medical coverage are two of the nine
major projects implemented by the Government. They are consistent with the Kingdom’s
poverty reduction policy, as indicated in the Government’s agenda (January 2012) and in the
30 July 2012 Speech from the Throne. After establishing medical coverage mechanisms for
public and private sector employees and the economically disadvantaged, the Government
plans to continue its efforts by developing similar mechanisms for the so-called “self-employed
workers”.
PARCOUM III will support structural reforms in social protection and help to cover the
Government’s agenda financing gap. This programme will enable the Government of Morocco
to define a long-term social protection vision for the entire population, taking into account
challenges related to the coordination and financing of the reform.
The Bank has acquired expertise in providing budget support to Morocco through various
operations, as well as unique knowledge about basic medical coverage reform because this is
its third reform support programme. The Bank’s specific comparative advantage lies in its
expertise in financing social services, social safety nets, and insurance mechanisms.
PARCOUM III will contribute to Morocco’s institution building by broadening and
strengthening the Inter-Ministerial Reform Committee. This will help to provide a
comprehensive and unified vision of long-term reform at the highest political level.
Furthermore, the programme will receive technical support to build institutional capacity and
provide analytical bases and know-how for the implementation of the reform.
iv
RESULTS-BASED LOGICAL FRAMEWORK
Country and Project Name: Morocco – Medical Coverage Reform Support Programme Phase III (PARCOUM III)
Project Goal: To improve social protection and medical coverage for the Moroccan population, particularly the most vulnerable segments of
the population, by extending basic medical coverage and access to quality health services.
IMPACT
OUTPUTS CHAIN
Impact: Improvement in
the health status of the
population, particularly
the most vulnerable
segments
PERFORMANCE INDICATORS
Indicator
Baseline
Target
(including ISC)
Case
Infant mortality 30
rate (/1 000)
(2011)
20 (2020)
Maternal
mortality rate
(/100 000)
80 (2020)
OUTCOMES
Ministry of Health
(ENPSF)
60% (2015)
ANAM (CHI
Balance Sheet),
Ministry of Health
(CNS)
Ministry of Health
(CNS)
Risk: Better health insurance coverage
does not result in increased demand for
health care
HCP (Household
Confidence Survey)
Risk: Health care delivery cannot keep
Share of direct
payments in
health expenses
53.6%
(2010)
48% (2015)
Proportion of
households that
feel that health
services have
improved
Number of
inhabitants per
public sector
physician
23%
(2012)
40% (2015)
2725
(2012)
2500 (2015) Ministry of Health
(health statistics)
Component 1: Steering and Financing of Basic Medical Coverage
0 (2013) At least two The Prime Minister’s
1.1 The reform steering Number of
meetings held
meeting
Office, the Interand governance
by the BMC
reports are
Ministerial
mechanism is
Intersubmitted
Committee (agenda)
strengthened
Ministerial
each year
Committee
0 (2013) 16 (2015)
Ministry of Health
1.2 Visibility on BMC Number of
programme
(transmission of
financing is
contracts signed
contracts)
guaranteed
with the regions
OUTPUTS
RISKS/
MITIGATION MEASURES
112
(2011)
Outcome 1: Physical
Population
49%
and financial access to
covered by CHI (2013)
health services improved and RAMED
Outcome 2: Delivery of
quality health care
improved
MEANS OF
VERIFICATION
Component 2: Extension of Basic Medical Coverage
% of population 63%
93% (2014)
2.1 RAMED
eligible for
(2013)
implementation is
RAMED
generalized
coverage
0 (2013) 200 000
2.2The coverage of self- New selfemployed
(2014)
employed workers
workers
has improved
affiliated to CHI
Component 3: Regulation and Delivery of Health Care
3.1 The availability and Average
61.6%
70% (2014)
quality of services hospital bed
(2011)
have improved
occupancy rate
(%)
3.2 Recourse to care is % of CHI
21%
40% (2015)
streamlined
policyholders
(2011)
who enjoy the
services of a
family doctor
v
ANAM (registration
monitoring balance
sheet)
CNSS (balance
sheet)
Ministry of Health
(health statistics)
ANAM (bi-annual
publication, CHI
Barometer)
Mitigation measure: Sensitization
campaigns carried out by ANAM and
MS, visibility is ensured by the King’s
commitment
pace with new demand on a relatively
short-term basis
Mitigation measure: Health care
delivery support is coordinated by donors
and sustained by Morocco’s State budget
Risk: Insufficient visibility regarding
resources allocated for the reform
Mitigation measure: Two conditions
relating to the Social Cohesion Support
Fund are included in the Programme
Risk: Delays in identification of RAMED
beneficiaries and distribution of cards
Mitigation measure: Measures are
adopted to improve the processing of files
and the targeting system
Risk: Mobilization of health care
providers and pharmacists to work in
disadvantaged regions falls short of
expectations
Mitigation measure: A series of
incentives are adopted to attract them to
disadvantaged regions
3.3 Citizen
participation and
accountability are
strengthened
The pilot project N.A.
for citizen
participation is
tested in a
region
The pilot
Validation of pilot
project
project by the
proposed by Ministry of Health
the Ministry
of Health is
tested
Mitigation measure: Measures to ensure
BMC financing visibility and improve
service availability as well as implement
measures relating to the LOF, programme
budgets and capacity building of IGMs
RESOURCES
KEY
ACTIVITIES
COMPONENTS
Component 1: Steering and Financing of BMC
Component 2: Extension of BMC
Component 3: Regulation and Delivery of Health Care
Risk: The initial sector fiduciary risk
assessed in the Ministry of Health is very
high
ADB: UA 100 million
EU: EUR 50 million
vi
PROGRAMME IMPLEMENTATION SCHEDULE
vii
REPORT AND RECOMMENDATION BY MANAGEMENT TO THE BOARD OF
DIRECTORS CONCERNING A PROPOSAL TO GRANT A LOAN TO THE
KINGDOM OF MOROCCO TO FINANCE THE MEDICAL COVERAGE REFORM
SUPPORT PROGRAMME - PHASE 3 (PARCOUM III)
1.
PROPOSAL
1.1
Management hereby submits this report and recommendation concerning a
proposal to grant a EUR 115 million loan to the Kingdom of Morocco to finance the Medical
Coverage Reform Support Programme (PARCOUM III). This is the Bank’s third sector
budget support programme to Morocco’s Ministry of Health. PARCOUM III was designed by
the Government of Morocco with the support of the European Union, which also backs the
reform through its third support programme in the form of a grant (Basic Medical Coverage or
BMC III). The programme was also designed in close collaboration with key development
partners, in particular the Spanish Agency for International Development Cooperation, the
World Health Organization (WHO), the French Development Agency (AFD), the World Bank
(WB) and the United Nations Development Programme (UNDP). Other stakeholders, including
civil society organizations (CSO) and Members of Parliament, were consulted.
1.2
PARCOUM III is aligned on ADB’s CSP 2012-2016 for Morocco. In spite of the
progress made, the CSP acknowledges that much remains to be done to ensure sustainable and
equitable improvement in social indicators. This programme will contribute to strengthening
governance and social inclusion, which is the theme of the first pillar of the CSP, by
consolidating social protection mechanisms for the population. In addition, by reducing
economic and social shocks, the programme will enable social outcasts and vulnerable people
to benefit from broad economic opportunities, thereby contributing to achievement of the
objective of inclusive growth outlined in the Bank’s Strategy for 2013–2022. Lastly, it will
contribute to achieving the human capital development strategy objectives relating to the
establishment of inclusive social and financial systems.
1.3
The programme is also consistent with the Government of Morocco’s agenda.
Morocco seeks to improve access to basic social services for the entire population by
developing social safety nets. The Medical Assistance Scheme for the Economically
Disadvantaged (RAMED) and basic medical coverage are two of the nine major projects
implemented by the Government. They are consistent with the Kingdom’s poverty reduction
policy, as indicated in the Government’s agenda (January 2012) and in the 30 July 2012 Speech
from the Throne. After establishing coverage mechanisms for public and private sector
employees and the economically disadvantaged, the Government plans to continue its efforts
by developing similar mechanisms for the so-called “self-employed” workers (see Technical
Annex V).
1.4
PARCOUM III will support implementation of the basic medical coverage reform
by guaranteeing vital social protection and health spending. The objective of this programme
is to improve social protection and medical coverage for the Moroccan population, particularly
the most vulnerable segments, by extending basic medical coverage and improving access to
quality health services. The programme will place emphasis on: (i) the steering and financing
of the reform; (ii) the extension of basic medical coverage; and (iii) the regulation and delivery
of health care so as to increase social protection and improve the health status of the Moroccan
population, particularly that of the vulnerable segments of the population.
1
2.
COUNTRY AND PROGRAMME CONTEXT
2.1
Government’s Overall Development Strategy and Medium-term Reform
Priorities
2.1.1
Recent political and social developments in Morocco highlight the importance
of the social dimension in Government’s policies. In fact, the statement issued by the
Government in January 2012 outlines an economic and social development programme based
on the implementation of far-reaching strategic reforms and sector policies centered around
major infrastructure projects. This programme, which is a follow-up to previous Government
action, seeks to meet the challenge of competitiveness and maintain macro-economic viability
in order to promote sustained growth capable of improving the living conditions of the
population on a sustainable basis. The guideline retained is based on five priority thrusts which
seek to: (i) deepen national identity and maintain the coherence and diversity of its components;
(ii) establish the rule of law, advanced regionalization and good governance; (iii) create
conditions for a strong, competitive and employment-generating economy; (iv) strengthen
Morocco’s national sovereignty and image; and (v) institute a new social pact which entrenches
solidarity between the various socio-economic groups and regions, while ensuring access to
basic social services.
2.1.2
Social protection, particularly through the extension of basic medical coverage
(BMC), is one of the priorities of the 2013-2016 Action Plan prepared by the Ministry of
Health. The Government intends to pursue the major structural reforms initiated in 2001 in
order to develop basic medical coverage. Special attention will be paid to the generalization of
RAMED which became effective following the speech made His Majesty the King on 13 March
2012 and to the extension of medical coverage to self-employed workers.
2.2
Recent Economic and Social Developments, Outlook, Constraints and
Challenges
Recent Political, Macro-economic and Social Developments
2.2.1
The
political
Table 1. Morocco: Key Macro-economic Indicators (2010-2018)
landscape,
which
is
2010 2011 2012 2013* 2014* 2015* 2016* 2017* 2018*
3.6 5 3.2 4.5
4.8
5
5.4
5.7
5.8
undergoing
profound Real GDP Growth Rate (%)
Non-agricultural Real GDP
changes, has improved Growth Rate (%)
4.9 5 4.5 4.5
4.7
5
5.4
5.8
5.9
significantly since the 2011 Inflation (% of period average) 1 0.9 1.2 2.4 2.5 2.5 2.5 2.6 2.6
Budget Balance (% of GDP)
-4.4 -6.1 -5.6 -4.7 -4.1 -3.5
-3
-2.7 -2.4
promulgation of the new Current Account Balance,
Constitution
which Including Official Transfers (%
of GDP)
-4.1 -8 -8.8 -6.3 -5.7 -5.3 -4.8 -4.5 -4.5
rehabilitates
political Total External Debt (% of GDP) 24.7 23.6 26.4 27.5 27.1 26.6 25.9 24.6 23.8
parties and the new organic Foreign Exchange Reserves (in
months of imports of goods and
law governing them. With services in the following year) 5.7 5.1 4.1 4.1 4
4
4
4
4.1
the enshrining of elections as Note: (*) projections. Percentages express annual variations.
the only means to achieve Source: Annex 4.
political legitimacy and democratic culture as the key to exercise power, political parties are
improving their functioning and opening up more and more to a new type of grass-roots
militancy. Recently, Morocco launched a national dialogue on civil society to strengthen the
new Constitution which gives civil society a prominent role in public life by controlling the
action of the executive and participating in the drafting of laws. This dialogue will culminate in
the diagnosis of the associations network and adoption of the rules of participatory democracy.
2
Table 2: The Most Remote Regions Have the
Highest Poverty Rates
1997/98
1998/99
1999/00
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Budget indices of the Ministry of Health (MS),
the State Master Budget (BGE) and PIB
2.2.2
Despite its vulnerability to exogenous shocks, the Moroccan economy remains
buoyant. It has a stable macro-economic framework and a diverse productive base. The annual
average economic growth rate has been 4.9% since
Figure 1: Budget Index Trends (1997-2010)
2000. This performance can be attributed to reforms
300
initiated during that period by the Government to
280
BMS
mitigate some “vulnerabilities”, particularly by
260
BGE
reducing deficits, improving economic productivity
240
PIB
and enhancing the country’s attractiveness for
220
foreign investments. Thus, after a slight slowdown
200
180
in 2012, the Moroccan economy is expected to
160
experience rapid growth in 2013. According to IMF
140
estimates, real GDP growth could range from 4.5%
120
to 5.8% between 2013 and 2018 (Table 1). This
100
assumption is based on increased agricultural
production and reduced budget deficit. However, it
seems to underestimate the impact of the economic
downturn in Europe (which accounts for 80% of Source: MEF and Authors
trade flows) and budgetary constraints which will inevitably limit public spending as evidenced
by the recent freezing of MAD 15 billion of the 2013 investment budget. Although there has
been an increase in public health spending in Morocco, it remains low. Over the past decade,
changes in the budget index of the Ministry of Health have been more significant than those in
the State budget and GDP. The 2013 budget of the Ministry of Health represents only 5% of
the recurrent State budget (as against 20% for the Ministry of National Education) (Figure 1).
Figure 2. The Richest Quintile Owns About Half of the
Country’s Wealth, 2007
Income share held by wealth quintile (%)
100
20% les plus
80
20%
richest
pauvres
Quintile 2
60
Quintile 3
40
Quintile 4
20
0
20% poorest
20% les plus
riches
Source: HCP (2007) – Survey on Household Living Conditions.
Source: ADB, 2011.
2.2.3
The social environment is marked by high income inequalities compounded by
regional and gender disparities. Despite an overall improvement in living standards (the
relative poverty rate at national level dropped from 15.3% to 8.9% between 2001 and 2007),
there are major differences between rural and urban areas and persistent social inequalities. The
relative poverty rate is 4.8% in urban areas as against 14.4% in rural areas (High Commission
for Planning, 2009). The poverty level varies from one region to another, with the South having
the highest rates (Table 2). Lastly, there are flagrant income inequalities with 20% of the richest
segment of the population controlling 48% of total income as against 7% for the poorest
segments (Figure 2). In addition, gender inequalities place women in a vulnerable position:
3
about one in two women is illiterate; women make up the majority of the non-working
population (according to the 2010 Employment Survey, the male/female activity ratio is 35%).
However, special attention is being paid to women’s status: the revision of the Family Code
and the adoption of measures to improve access to health care and education.
Outlook, Constraints and Challenges
2.2.4
The population is dissatisfied with social policies, governance and the quality
of public services in Morocco. Since 2005, the Moroccan Government, with donor support,
has embarked on major social projects, including the National Human Development Initiative
(INDH) which supports income-generating activities and the Medical Assistance Scheme for
the Economically Disadvantaged (RAMED). However, Moroccans seem to be dissatisfied with
the manner in which the Government is providing assistance to the poor: only 30% of the
Moroccan population is satisfied, compared to more than double this percentage in Tunisia and
Jordan (World Bank, 2012).
2.2.5
Improvements in health and health service use indicators fell short of
expectations given the country’s GDP per capita. Infant mortality in Morocco seems to be
higher than that in a number of countries with a comparable per capita income level (Figure 3).
The maternal mortality rate is 112 per 100 000 live births, with a relatively low level of recourse
to prenatal, postnatal and delivery care in medical establishments (HCP 2011, Ministry of
Health 2011).
Figure 3: Infant Mortality in Morocco Remains
High
Figure 4: Malnutrition (Moderate or Severe) is
Higher Among Rural Children
Source: Ministry of Health (2011) – National Population and Family Health Survey (NPFHS 2011).
2.2.6
There are wide disparities in access to health care based on environment
(urban/rural), gender and income bracket. Poverty and living in rural areas are two key
determining factors of infant and maternal mortality. Maternal mortality in rural areas in
Morocco is 43% higher than in urban areas. Under-five children in the poorest quintile are three
times more likely to die of often easily treatable childhood diseases or preventable injuries. The
proportion of children suffering from chronic malnutrition (stunting) is much higher in rural
areas than in urban areas (20.5% as against 8.6%) (Figure 4).
2.2.7
Access to health care is limited by narrow health risk coverage. Although the
Moroccan Government has made significant efforts to improve access to health care, more than
half of the population (51%) do not benefit from a risk protection mechanism. About
4
Figure 5: The Level of Registration in RAMED Varies from
one Region to Another, 2013
Source : ANAM (2013)
34% of the population (10.7 million
people) is covered by a health
insurance through the Compulsory
Health Insurance (CHI) scheme,
internal and mutual schemes, and
insurance companies. About 15% of
the population was covered by
RAMED at the end July 2013 (5.1
million people)1. Lastly, the group
made up of “self-employed
workers”, which is estimated at
about 10 million people, is at the
moment excluded from BMC
(Technical Annex V). There are
also wide disparities in medical
coverage. Subscriptions to RAMED
reveal wide regional disparities
(Figure 5).
2.2.8
The BMC will face challenges in the future. The achievements outlined above in
terms of coverage for the underprivileged should be consolidated and expanded so as generalize
BMC in an equitable and sustainable manner. Like other developing countries that have opted
for the development of health insurance, Morocco faces complex problems (medical coverage
for self-employed workers; financing of various insurance schemes; implementation of the
principle of solidarity; regulation of the drug market) which require fundamental choices that
may commit the country in the long term.
Figure 7. Public Health Expenditure Accounts for
Only One-Third of Total Health Expenditure
Figure 6: Direct Household Payments Account for
More Than 50% of Total Health Expenditure
100
90
80
70
60
50
40
30
20
10
0
1998 2001 2006 2007 2008 2009 2010
Private health expenditure
Source: National Health Accounts (2010).
Public health expenditure
Source: National Health Accounts (2010).
1
However, this rate is expected to reach 26% when the whole target population will be covered.
5
2.2.9
Health expenses in Morocco constitute a heavy burden for Moroccan
households and expose them to the risk of impoverishment due to disease. Households bear
more than half of total health expenditure (53.6%). Since 1998, their contribution has remained
stable, but for a shift in recent years, which needs to be amplified. Health insurance contributes
only 18.8%, the State 25.2% and employers and international cooperation 1% each (Figure 6).
This health expenditure distribution exposes households, particularly the most vulnerable, to
the risk of very high expenses. It is thus estimated that 1.9% of the Moroccan population incur
extremely high expenses and that 1.4%, particularly people living in rural areas, grow poorer
owing to such expenses (WHO 2007).
2.2.10
Although there has been an increase in public health spending in Morocco, it
has remained low and relatively stable over the past five years. In fact, since 2007, public
health spending has hovered around 34% of total health expenditure – with the remaining twothirds being financed privately, mainly through direct payments by health service users (Figure
7).2
2.3
Sector and Related National Programmes
2.3.1
Morocco seeks to improve access to basic social services for the entire
population by developing basic medical coverage. After establishing medical coverage
mechanisms for public and private sector employees and the economically disadvantaged, the
Government plans to continue its efforts by developing similar mechanisms for the so-called
“self-employed workers”. RAMED and BMC fall within the Kingdom’s poverty reduction
policy.
2.3.2
The new health sector strategy for the 2013-2016 period will help to consolidate
activities carried out during the preceding period. The challenges listed in the 2012-2016
Action Plan, which serves as an operational document for the implementation of the strategy,
are: (i) global health security; (ii) human resources for health; (iii) primary health care reform;
(iv) strengthening of health systems; (v) universal health coverage; and (vi) non-communicable
diseases. The new sector strategy is being validated.
2.4
Bank Group Portfolio Status
2.4.1
The ADB is currently Morocco’s leading development partner, with a
commitment volume of EUR 2.4 billion. The Bank’s active portfolio in Morocco comprises
29 operations, comprising 15 loans totalling UA 2 billion (99.6%) and 14 grants totalling UA
7.4 million (0.4%). Bank approvals increased more than six fold between 2008 and 2012, from
EUR 158 million to EUR 1 076 million at the end of April 2013. To date, the portfolio has only
one potentially problematic project in the transport sector.
2
Technical Annex IV presents a more detailed analysis of health financing in Morocco.
6
3.
RATIONALE, KEY DESIGN ELEMENTS, AND SUSTAINABILITY
3.1
Linkage with the CSP, Country Readiness Assessment and Analytical Bases
3.1.1
Linkage with the CSP. Thanks to the establishment of a social safety net for
the population, PARCOUM III will contribute to strengthening governance and social
inclusion, which is the theme of the first pillar of CSP (2012-2016). In fact, despite the
progress made, the CSP indicates that much remains to be done to ensure sustainable and more
equitable improvement in social indicators.
3.1.2
Country readiness assessment and compliance with the Bank’s safeguards
policy. Morocco fulfils all the conditions of eligibility for a budget support operation
(Table 3). The country also had a Country Policy and Institutional Assessment (CPIA) rating
of 4.2 in 2011 and a Standard & Poor’s Sovereign Investment Grade rating of “BBB-” in March
2010. The agency attributes this rating to a strong growth rate, low inflation and limited debt.
However, Standard & Poor’s revised its rating outlook from “Stable” to “Negative” in October
2012 due to the deterioration of the country’s budget and current account balances. Despite
such rating, the country successfully raised two bond loans totalling USD 1.5 billion3 in
December 2012.
Table 3
Conditions Precedent to Sector Budget Support
Conditions
Precedent
Government’s
commitment to
poverty reduction
Macro-economic
stability
Satisfactory
fiduciary risk
assessment
Political stability
Harmonization
3
Remarks
The Government prepared a programme that was approved by Parliament in February
2012; the programme defines the various actions to be carried out in all economic and
social sectors in the country for the 2013-2018 period, and is consistent with the
Government’s priorities and poverty reduction policy. The Government has
demonstrated its commitment to embark on structural reforms by implementing Public
Administration Reform Support Programmes (PARAP I to IV), Financial Sector
Development Support Programmes (PADESFI I and II), and PARCOUM I and II.
Morocco has experienced sustained economic growth over the past five years with an
average growth rate of about 5%, an inflation rate of 1.2% in 2012 and a relatively
controlled budget and balance of payments deficit. This economic stability was
achieved despite the impact of the global financial crisis, whose effects were mitigated
by a series of emergency budgetary and fiscal measures adopted by the Government.
At end-2012, the budget deficit was 5.6% of GDP (as against 6.1% in 2011), the current
account deficit was 8.8% of GDP, and international reserves dropped to four months of
exports.
According to the most recent diagnosis and assessments of public finance management,
procurement and the level of corruption, the country’s fiduciary risk is considered to
be moderate and could be reduced to a low residual risk level. An assessment of
fiduciary risks specific to the sector was carried out during the appraisal mission. The
initial fiduciary risk is considered to be substantial, and the recommended mitigation
measures could reduce it to a moderate level at the end of the operation (see Technical
Annex II).
Morocco enjoys solid political stability. Free and fair elections are organized regularly
and the country amended its Constitution recently, allowing for peaceful elections and
change of Government.
Morocco maintains good partnership relations with the donor community that support
the Kingdom through various instruments, including sector budget support. Such
partnership has helped to implement major programmes. Morocco has a functional
framework for aid harmonization. The first two PARCOUM were supported jointly by
With an interest rate of 4.25% for the USD 1 billion tranche with a 10-year maturity and 5.5% for the USD 500 million tranche with a 30year maturity
7
the ADB and the European Union. This programme will also be supported by both
institutions.
3.1.3
Analytical works and bases. The programme design is based on key economic
and sector studies. Major studies, particularly studies on self-employed workers (the situation
of the self-employed, benchmark, proposed scenarios and actuarial study), RAMED’s actuarial
study and various CHI reports produced by ANAM4, have helped to define the programme
thrusts. Other studies will be carried out during programme implementation. Thus, PARCOUM
III will be supported by at least three technical assistance operations: a study on the design of a
health financing strategy (in the process of being launched); support for the development of
citizen participation and accountability mechanisms in the sector (financing pending
confirmation) and an MIC grant for the establishment of a geographic information system to
support preparation of the health map (approved by the Vice-President of OSVP on 31 July
2013).
3.2
Collaboration and Coordination with Other Donors
3.2.1
The Bank will maintain its cooperation with the European Union and
strengthen ties with its key technical and financial partners (TFPs). The Bank and the
European Union have jointly provided support for the BMC reform from its inception
(PARCOUM I and II). The proposed programme will also enjoy joint support. The Bank will
also maintain partnership relations with other TFPs such as WHO, the Spanish Agency for
International Development Cooperation, AFD and the World Bank.
3.2.2
Activities of development partners in the country. Many partners provide
support to the various thrusts of Morocco’s health sector strategy. WHO jointly
implements programmes with the Ministry of Health and provides support for capacity building
and the preparation of national health accounts. A study on social health indicators is being
finalized. A multi-donor group comprising AFD, the EU Delegation, the Spanish Agency for
International Development Cooperation and UNFPA has developed a health sector strategy
support programme (PAS Santé). Since 2006, the European Investment Bank (EIB) has been
financing a programme to renovate and modernize health care infrastructure and existing
medical equipment for an amount of EUR 70 million. JICA is supporting many training and
technical assistance operations, particularly in the area of maternal and child health.
3.2.3
A participatory approach was adopted during programme design to take into
account the needs of each stakeholder. The key stakeholders and beneficiaries (self-employed
workers, Members of Parliament, civil society, TFPs and the Government) were consulted
during the preparation and appraisal missions. Discussions and comments on the matrix
underscored the existence of consensus on the proposed thrusts. It was also necessary to try as
much as possible to involve civil society organizations in some sensitization activities,
particularly for RAMED. However, although the new Constitution recognizes the role of civil
society organizations as full-fledged public policy actors, the legal framework for its application
is still being prepared with the Bank’s support.
3.3
Outcomes and Lessons Learned from Similar Past and Ongoing Operations
3.3.1
The programme design takes into account the recommendations of
PARCOUM I and II concerning the aspects that impeded their implementation.
4
All the economic and sector studies used to design this technical programme are presented in Technical Annex I.
8
PARCOUM I (2005-2008) supported the introduction of compulsory health insurance for
formal public and private sector employees. For its part, PARCOUM II (2008-2012) supported
the establishment of RAMED. PARCOUM III seeks to expand BMC by generalizing RAMED
and establishing a special scheme for self-employed workers. To improve the institutional
framework for coordinating the reform at the political and technical levels (recommendation of
PARCOUM I completion report), thrust 1 of the new programme is devoted entirely to
governance of reform. Furthermore, administrative conditions that can easily be fulfilled by
technical services are preferred to legal conditions that are difficult to comply with
(recommendation of PARCOUM I Completion Report). Similarly, in line with the
recommendations of PARCOUM II, the disbursement conditions chosen are those that can be
fulfilled and will not delay programme implementation. Lastly, to achieve the best results, thrust
3 has been designed to facilitate implementation on the ground and for the beneficiary
populations. The Bank will also seek to provide more technical assistance to support this
programme, in coordination with other partners (recommendations of PARCOUM II
completion report). Technical Annex VI further clarifies the manner in which the lessons
learned from previous programmes have been taken into account.
3.4
Linkage with Bank Ongoing Operations
3.4.1
PARCOUM III complements other Bank programmes. This programme seeks
to establish a social and financial safety net for the Moroccan population so as to cover a greater
proportion of the population, particularly the vulnerable segments, and ultimately ensure more
inclusive growth. Accordingly, it complements PARGEF whose objective is to improve State
efficiency in the provision of quality public services to promote inclusive economic growth; it
also complements PAAFE that is being prepared and which will promote social inclusion by
improving youth training and employability. In addition, just like PAAFE, PARCOUM III
seeks to strengthen sector governance. The programme also complements the Green Morocco
Plan Support Programme, which mainly seeks to reduce poverty in rural areas and create
conditions for more inclusive growth by strengthening the competitiveness of the agricultural
sector.
3.5
The Bank’s Value Added and Comparative Advantage
3.5.1
The Bank has acquired solid expertise in budget support to Morocco through
various operations, as well as in BMC reform as this is its third reform support
programme. The ADB’s specific comparative advantage for reform support lies in its expertise
in financing social sectors, social safety nets and health insurance. Attention is regularly drawn
to this comparative advantage by the Moroccan authorities, and it enables the Bank to maintain
a high-level sector policy dialogue with them.
3.5.2
PARCOUM III will help to strengthen the Bank’s action in the governance
sector by ensuring social and economic inclusion and focusing on issues related to financing,
cost control, regulations and citizens’ opinions. It will therefore contribute to achieving the
objective of the Bank’s Strategy for 2013-2022 to enhance inclusive growth, particularly its
operational priority regarding governance and accountability. Thus, the strategy seeks to
“support countries in the implementation of social protection programmes” because they
contribute to the inclusion of the most vulnerable and disadvantaged groups and poverty
reduction. The programme will also help to achieve the human capital strategy objectives of
developing inclusive social and financial systems.
9
3.6
Application of Principles of Optimal Conditionality Practices
3.6.1
PARCOUM III has drawn on good conditionality practices (Technical Annex
I). This concern justifies the limitation of the number of measures triggering disbursements, as
well as efforts made to ensure their ownership. The measures focus on key realistic and feasible
reform actions in the medium term which significantly impact implementation of the reform.
Some measures were adopted by mutual agreement with the EU.
4.
PROPOSED PROGRAMME
4.1
Programme Goal and Objective
4.1.1
The programme seeks to support the Kingdom of Morocco’s efforts to promote
universal social protection coverage. It aims to improve social protection and medical
coverage for Moroccans, particularly the most vulnerable people, by extending basic medical
coverage and access to quality health services. To that end, the programme focuses on: (i) the
steering and financing of reform; (ii) the extension of medical coverage; and (iii) regulations
and delivery of health care.
4.1.2
The programme is designed as a sector budget support to the Ministry of
Health to reduce health and social protection spending. The Bank’s financing will lighten
the burden of implementing reforms in these areas so as to advance the efforts initiated by the
Moroccan Government in 2005.
4.2
Programme Components, Operational Policy Objectives and Expected
Outcomes
Component 1: Steering and Financing of Basic Medical Coverage
4.2.1
The objective of this component is to support the governance of basic medical
coverage reform and ensure sustainability of its financing. To that end, PARCOUM III will
support the rehabilitation of the Inter-Ministerial Reform Committee chaired by the Head of
Government to ensure a long-term strategic vision of reform and strengthen BMC financing
and management tools.
Sub-component 1: Strengthening the Steering and Governance of Basic Medical Coverage
Reform
4.2.1.1
Context: Law No. 65-00 on basic medical coverage provides for access to health
care for all Moroccans through universal basic medical coverage. Section 1 of this law,
which came into force on 1 September 2005, provides for the financing of health care services
based on the principles of solidarity and equity so as to guarantee access to health care for the
entire population. The law provides for a Compulsory Health Insurance (CHI) scheme for
public and private sector employees, self-employed workers, liberal professions and other selfemployed persons. It also provides for a medical assistance scheme (RAMED) and establishes
the National Health Insurance Agency (ANAM) which has, since 2009, been placed under the
supervisory authority of the Ministry of Health. According to the law, ANAM’s role is to ensure
the technical supervision of CHI and the design of the system’s regulatory instruments (Section
59) and to manage resources allocated to RAMED.
10
4.2.1.2
Rationale: Despite the significant progress made in the implementation of the
reform, Morocco is still facing difficulties in steering and governing it. So far, efforts to
coordinate BMC have been focused on RAMED and its extension, while public and private
sector employee management bodies have coordinated the CHI scheme. There are isolated
initiatives regarding health insurance for self-employed workers, which may lead to fragmented
development of health insurance. Furthermore, ANAM does not have adequate financial
resources and institutional arrangements that would enable it to assume all the prerogatives
provided for by the law. In this context and given the scope of the reform, there is a need to
introduce mechanisms to ensure its governance and steering at the highest level.
4.2.1.3
Measures Supported: The proposed sector budget support will strengthen
BMC reform steering and governance. Accordingly, PARCOUM III will support: (i) the
extension and strengthening of the Inter-Ministerial Reform Committee and, the following year,
the holding of bi-annual meetings whose minutes will be submitted to the Bank; (ii) the
establishment of a technical committee to regularly monitor programme implementation status,
carry out analyses and prepare technical documents for the Inter-Ministerial Committee; and
(iii) the preparation and presentation, to the Inter-Ministerial Committee, of a plan to improve
RAMED management tools and institutional arrangements which are now inadequate.
4.2.1.4
Expected Outcomes: The expected outcomes are the establishment of institutional,
policy and technical mechanisms for long-term reform implementation. Reform options will
also be considered.
Sub-component 2: Ensuring Sustainable Financing of Basic Medical Coverage
4.2.1.5
Context: Law No. 65-00 defines guidelines for the financing and management
of BMC, but its implementation is fraught with difficulties. According to this law, CHI is
based on the principles of contribution and risk sharing, while RAMED is based on the principle
of national solidarity for disadvantaged people. Section 73 provides for two CHI management
bodies: the National Social Security Fund (CNSS) for private sector employees and the National
Fund for Social Security Agencies (CNOPS) for public sector employees. For its part and
according to the law, ANAM is responsible for the financial management of RAMED. The
Social Cohesion Support Fund (FCS) was set up in the MEF in 2012. The Fund is mainly
responsible for financing health services provided to RAMED beneficiaries.
4.2.1.6
Rationale: Given the rapid expansion of health insurance coverage, the issue
of financing the reform and ensuring its financial sustainability is crucial. Indeed, Morocco
is currently experiencing an unprecedented increase in the population covered by health
insurance due principally to the generalization of RAMED. However, difficulties in
maintaining the financial equilibrium of CHI management bodies and the absence of a RAMED
management body may result in cost escalation which Morocco may be unable to cope with. It
is therefore necessary and urgent to develop tools to ensure proper management and sustainable
financing of the insurance system.
4.2.1.7
Measures Supported: The programme will support tools that would ensure
sustainable BMC financing. PARCOUM III will support measures to ensure proper functioning
of the Social Cohesion Support Fund by: (i) mobilizing resources for RAMED, and (ii) ensuring
that MEF transfers resources from the Social Cohesion Support Fund to RAMED. The ADB
will also back measures to improve the planning and budgeting of resources in the health sector,
such as: (i) submission of the health sector financing strategy by the Ministry of Health, (ii)
11
introduction of programme budgeting in the Ministry of Health, and (iii) signing of programme
contracts with health regions.
4.2.1.8
Expected Outcome: The expected outcome is the development of financial
instruments to ensure better visibility in reform financing.
Component 2: Extension of Basic Medical Coverage
4.2.2
The objective of this component is to support Morocco in its efforts to extend
protection against health risks to the entire population. To that end, PARCOUM III will
support the generalization of RAMED and establishment of a scheme for self-employed
workers.
Sub-component 1: Strengthening the Implementation of the Medical Assistance Scheme
(RAMED)
4.2.2.1
Context: Although Law No. 65-00 provides for universal basic medical
coverage, less than half of the population benefit from a health insurance scheme. On 13
March 2012, the King of Morocco announced the generalization of RAMED across the country
after the pilot experiment in Tadla-Azilal Region. The target population all over the country is
estimated at 8.1 million. However, some regions have already recorded a registration rate of
more than 100%. In April 2013, 65% of the target population (5.5 million people) had access
to health care and 48% had RAMED membership cards. As regards beneficiaries of the CHI
scheme, more than 8 million people are already covered, but some have not yet switched to
CNOPS or CNSS. Indeed, Section 114 of Law No. 65-00 specifies that as a transitional
measure, public or private bodies providing optional medical coverage to their employees can
continue to provide such coverage.
4.2.2.2
Rationale: Despite progress made in the generalization of RAMED, there are
still obstacles to effective coverage. Local standing committees in charge of processing
registration files have difficulty in meeting deadlines for processing applications due to the
limited means at their disposal. Furthermore, in spite of improvements following assessment of
the pilot test in Tadla-Azilal Region, the RAMED targeting system has some shortcomings
which should be corrected to avoid errors of exclusion. Lastly, the coverage of public and
private sector employees by the CHI scheme is incomplete. Although the transitional period
(Section 114) has ended, about 1.2 million people in the public sector and 1.6 million in the
private sector5 have not yet been included in the CHI scheme.
4.2.2.3
Measures Supported: PARCOUM III will support measures to strengthen
RAMED implementation. Furthermore, the programme will ensure inclusion of the so-called
Section 114 population by monitoring the increase in the CHI-affiliated population. Given the
significant progress made in terms of RAMED coverage, the programme will not focus on
RAMED-related quantitative aspects, but rather on qualitative aspects to improve its
functioning and benefits for the Moroccan population. The programme will therefore support:
(i) the interconnection of related administrative services to improve the processing of files; (ii)
the use of the findings of the actuarial study on RAMED financing scenarios; and (iii)
discussions within the Inter-Ministerial Committee on the possibility of reviewing the RAMED
targeting system so as to establish it as a targeting system for social programmes in Morocco.
4.2.2.4
Expected Outcomes: It is expected that 93% coverage of the RAMED target
population will be achieved at the end of the programme. It is also expected that the processing
5
ANAM. 2011 CHI Balance Sheet
12
of RAMED files, including the renewal of registration cards, and areas for improvement in the
identification of beneficiaries, will be improved.
Sub-component 2: Developing Medical Coverage for Self-Employed Socio-professional
Categories
4.2.2.5
Context: To date, about one-third of the Moroccan population is excluded
from CHI. According to the headcount of self-employed workers6, the total population of selfemployed workers is nearly 3.4 million, or about 10 million people with their dependents. This
population is very heterogeneous (liberal professions, traders, craftsmen and itinerant workers).
The best organized and most solvent already have a private health insurance coverage for their
corporation (e.g. lawyers), but the most disadvantaged do not enjoy any coverage.
4.2.2.6
Rationale: Although Law No. 65-00 provides for the coverage of self-employed
workers by the CHI scheme, the scenario and practical arrangements for the coverage of
this population are still to be defined. Indeed, at present, there is no official stance on
mechanisms for the coverage of the population concerned. The absence of a scheme for these
people, who are often poor, poses a high risk of switch to RAMED. An urgent solution must be
sought for this population, while avoiding the risk of fragmentation of schemes.
4.2.2.7
Measures Supported: PARCOUM III will support the development of medical
coverage for self-employed socio-professional categories. It will ensure that tangible
progress is made towards establishment of a scheme for self-employed workers by: (i)
proposing scenarios for the coverage of self-employed workers; (ii) presenting a draft strategy
for the coverage of self-employed workers to the Inter-Ministerial Reform Committee; (iii)
including canoe builders in the CNSS; and (iv) presenting a bill on the coverage of students to
the Council of Ministers.
4.2.2.8
Expected Outcomes: The expected outcomes are the gradual inclusion of some
categories in the CHI scheme with at least 200 000 additional members at the end of the
programme and the development of a long-term strategic vision for the coverage of selfemployed workers.
Component 3: Regulation and Delivery of Health Care
4.2.3
This component seeks to support the extension of basic medical coverage by
supporting regulation and delivery of health care. Indeed, within a context where demand
for health services is supported through access to health insurance, it is important to ensure that
users have access to adequate and quality health services.
Sub-component 1: Improving the Availability and Quality of Services
6
General study for the proposal of compulsory health insurance scheme coverage scenarios for self-employed workers and liberal
professions.
13
4.2.3.1
Context: Law No. 34-09 of July 2011 on the health system and health care
delivery defines the basic principles and objectives of State action regarding health care
as well as the organization of the health system. It defines the content of health care delivery,
particularly with regard to human resources, health infrastructure, public-private partnerships,
the health information system, the health map and regional health care delivery systems.
4.2.3.2
Rationale: In Morocco, it is necessary to improve the availability and quality
of services, particularly those for public sector users (most of whom are RAMED
subscribers) who are the most vulnerable. The country suffers from a huge human resource
shortage and inadequate personnel training capacity. In addition, the further training
programme should be strengthened and consolidated.
4.2.3.3
Measures Supported: PARCOUM III will support measures to improve the
availability and quality of human resources across the country, particularly by
strengthening synergy with the private sector. The programme will support measures to
enhance the deployment of health personnel by: (i) adopting an instrument to deconcentrate
human resource management procedures; (ii) submitting the draft decree on private sector
physicians and dental surgeons to the Secretariat General of the Government (SGG) to allow
for implementation of Law No. 34-09; and (iii) submitting the bill on the health map and
regional health care delivery systems to the SGG. Furthermore, in order to improve the practices
of the personnel in service, the programme will support: (i) the draft instrument to subject
promotion to further training so as to make it more attractive, and (ii) the adoption of rules of
good practice for standardized and quality treatment of patients.
4.2.3.4
Expected Outcome: The expected outcome is improved availability of quality
services, particularly an increase in the average bed occupancy rate from 61.6% to 70%, at the
end of the programme.
Sub-component 2: Streamlining Health Care Service Utilization
4.2.3.5
Rationale: The current regulations on health care delivery in Morocco do not
allow for optimal health service delivery, resulting in financial and health consequences
for the population. The absence of a “gate-keeper” for access to health care and the prohibitive
price of drugs, coupled with their short supply, are major impediments to the judicious
utilization of health services in Morocco. Lastly, regulations on the price of medical
interventions and pharmaceutical products are unsuitable and difficult to implement. Thus, the
price of brand-name drugs is 30% to 189% higher than in Tunisia and 20% to 70% higher than
in France. Rural and vulnerable households have limited access to drugs and bear a very heavy
financial burden due to the expenses they must incur on drugs.
4.2.3.6
Rationale: With the extension of RAMED and expansion of BMC to people not
yet covered, it is essential to support measures to ensure that supply satisfies demand. To
control health service costs and ensure the optimal utilization of health care providers, it is
necessary, like in other countries that have introduced health insurance mechanisms, to establish
a standard health care delivery system that must be followed. The price of drugs should also be
better regulated.
14
4.2.3.7
Measures Supported: PARCOUM III will support Government’s efforts to
streamline health care service utilization. Thus, the programme will support: (i) the adoption,
by ANAM Board of Directors, of a coordinated project for the medical follow-up of chronic
pathologies, and (ii) submission, to the Secretariat General of the Government, of a draft decree
to define the terms and conditions for fixing the prices of drugs sold to the public.
4.2.3.8
Expected Outcome: The expected outcome is the streamlining of the use of health
care services, with an increase in the number of CHI policyholders with family doctors from
21% to 40% in 2014.
Sub-Component 3: Strengthening Accountability
4.2.3.9
Context: The culture of accountability is not entrenched in Morocco. The
existing accountability mechanisms, such as complaints to the General Inspectorate of the
Ministry of Health and written complaints to health facilities, do not provide the expected
answers as health service users lack information on the outcome of their complaints. The level
of satisfaction with health services is very low.
4.2.3.10 Rationale: Morocco’s new Constitution recognizes the right to health services
and the principle of accountability. Within this context, it is necessary to put in place
mechanisms that provide feedback on users’ perception of care quality so as to make health
facilities accountable, ensure the quality of service delivery, and build trust between users and
service providers.
4.2.3.11 Measures Supported: To strengthen accountability, PARCOUM III will
support measures to empower health service users. Thus, the programme will help to foster
sector policy dialogue on: (i) the evaluation of the pilot project for the management of
complaints in hospitals through complaints filed online and by phone, and (ii) publication of
the RAMED Barometer.
4.2.3.12 Expected Outcomes: The expected outcomes of this sub-component are the
promotion of citizens’ opinions in Morocco, and implementation of a pilot project as proposed
by the Ministry of Health.
4.3
Implementation Status of Programme Reforms
4.3.1
In line with the commitments made by the Moroccan Government during the
appraisal mission, the presentation of the programme to the Bank’s Board of Directors is
subject to fulfilment of the conditionalities (measures 1 to 4 of the table below). The
disbursement of the second tranche in 2014 will be subject to fulfilment of measures 5, 6 and
7. The measures in italics are conditionalities shared by the EU.
15
Table 4
Reform Measures that will trigger Disbursement
Conditions Precedent to
Board Presentation (2013)
Evidence Required (2013)
1.
Extension
to
all
stakeholders
and
strengthening of the InterMinisterial Committee on
Strategic
Reform
Orientations and Decisions
Submission
of
correspondence
between the Ministry of the Economy
and Finance and the Head of
Government on the extension and
strengthening of the Inter-Ministerial
Committee specifying the duties and
list of committee members.
Letter by the Head of Government
establishing the Technical Committee
and specifying its role and
composition.
2. Establishment of the
Programme
Technical
Committee chaired by the
Head of Government or
Minister designated for that
purpose by the Head of
Government
3. Mobilization of
resources allocated to
RAMED
4. Proposal of scenarios for
the coverage of selfemployed workers
4.4
Submission of: (i) FCS’s 2013
Provisional
Employment
Programme; (ii) decisions to grant
subsidies to CHU specifying that the
resources are intended for RAMED
beneficiaries; and (iii) copies of
statements by the General Treasury of
the Kingdom showing FCS’s account
balance as at 31 December 2012 and
31 July 2013
Cover letter of proposed scenarios for
the coverage of self-employed
workers sent by MS to the Head of
Government
Conditions Precedent to Second
Tranche Disbursement (2014)
5.
Presentation,
by
the
Technical Committee to the
Inter-Ministerial Committee, of
the plan for the improvement of
institutional arrangements and
tools for the management of
RAMED
Evidence Required (2014)
6. Transfer of resources from
the Social Cohesion Support
Fund to RAMED by MEF
Submission of the FCS’s 2014
employment
programme
endorsed by the Ministry of the
Economy and Finance and
evidence of the transfer to
RAMED of the resources
indicated
in
the
2013
employment programme
Submission of the draft decree
on the status of private sector
physicians and dental surgeons
registered with the Ministry of
Health forwarded to the
Secretariat General of the
Government, including a copy
of the cover letter
7. Submission, to the SGG, of the
draft decree on the status of
private sector physicians and
dental surgeons registered with
MS.
Submission, to the InterMinisterial Committee, of the
plan for the improvement of
institutional arrangements and
tools for the management of
RAMED
Financial Requirements and Financing Arrangements
4.4.1
Morocco’s financial requirements for 2013 amount to MAD 66.5 billion, which
is to EU 6 billion (Table 5). These requirements will be covered partly by the country’s own
resources (EUR 5.4 billion, or 89.8%) and by external resources (EUR 0.6 billion, or 10.2%).
The external resource requirements will be met partly by external drawings on loans for
investment projects and reform programmes. The Bank loan amounting to EUR 115 million,
which will be disbursed in two tranches, will help to cover 9.7% of external financing in 2013
and 6.2% in 2014. An equivalent amount will also be allocated under the PAAFE in 2013 and
2014. In 2011, the health budget represented 6.5% of total public expenditure and 2.1% of GDP.
Table 5
Estimated Budget Balance and Financing Requirements 2012-2015 (in MAD billion)
Items
Total revenue (excluding Hassan II Fund and transfers to
local authorities)
Of which: Tax revenue
Non-tax revenue (excluding privatization
and Hassan II Fund)
Revenue of some special Treasury accounts
Net expenditure and loans (excluding Hassan II Fund)
Of which: Current expenditure
Capital expenditure
Overall balance (commitment basis, excluding Hassan II
Fund)
Grants
Variations in arrears
Other revenue
16
2012*
188.5
2013**
215.2
2014**
239.0
2015**
259.3
TOTAL
902.0
170.7
14.6
3.2
221.1
19.1
239.0
20.6
259.3
22.3
890.1
76.6
3.2
237.1
194.1
46.0
-48.6
284.2
209.7
47.1
-69.0
300.6
220.1
50.8
-61.6
320.6
233.2
55.0
-61.3
1.142.5
857.1
198.9
-240.5
-17.0
5.0
2.5
0.0
0.0
2.5
0.0
0.0
2.5
0.0
0.0
7.5
-17.0
5.0
Overall balance (cash basis, excluding Hassan II Fund)
-60.6
-66.5
-59.1
Financing (= - overall balance cash basis)
60.6
66.5
59.1
Domestic financing
47.3
59.7
52.0
External financing
13.3
6.8
7.1
Source: * Government of Morocco, August 2012. ** IMF Article IV of November 2011
4.5
-58.8
58.8
51.2
7.6
-245.0
245.0
210.2
34.8
Programme Beneficiaries
4.5.1
The entire Moroccan population will benefit from the programme. Indeed,
PARCOUM III seeks to support the extension of social health coverage to the entire population,
with priority given to the extension of coverage for the most vulnerable segments through
RAMED (28% of the population) and the establishment of a scheme for self-employed workers
(about 32% of the population). The latter will help to cover informal sector workers (85% of
self-employed workers), a large majority of whom are women who have attained the limit of
eligibility for RAMED. Furthermore, due to its regulation and health care delivery support, this
programme will be beneficial to all health service users, particularly in the public sector and
disadvantaged regions. Lastly, the programme will benefit all institutions, which will receive
technical support (steering committee, technical committee, MS, etc.).
4.6
Programme Impact on Gender
4.6.1
Women will be the main beneficiaries of this programme. Indeed, women of
childbearing age are the primary users of health care services for pregnancy care and childbirth
and its after-effects. Women are also often responsible for children’s health. In addition, gender
inequalities in Morocco place women in a vulnerable position and the female/male activity ratio
is 35%. This programme, which lays special emphasis on informal sector workers and the poor,
will therefore benefit women in particular. Furthermore, although health insurance coverage
cannot be assessed according to sex (as membership is done on a household basis)7, special
attention will be paid to improving women’s access to health care.
4.7
Environment and Climate Change
4.7.1
The Bank classifies this budget support programme in environmental category
III. Given that PARCOUM III is a sector budget support operation, the reforms it is expected
to support will have no direct negative impact on the environment. In addition, Morocco signed
the Framework Convention on Climate Change in Rio in 1992 and ratified it on 28 December
1995. It also ratified the Kyoto Protocol on 25 January 2002. Despite its negligible contribution
to overall global emissions, Morocco is making every effort to raise public awareness and
develop appropriate legal and regulatory frameworks.
7
Thus, CLAR indicators cannot be disaggregated by sex, but the impact indicator concerns women
17
5.
PROGRAMME IMPLEMENTATION, MONITORING AND
EVALUATION
5.1
Implementation Arrangements
5.1.1
Responsible institution: The Ministry of Health will be the main institution
responsible for implementation of PARCOUM III, like for the other two previous
programmes. The MEF will be involved in programme management and monitoring, as well
as fulfilment of some disbursement conditions related to financing of the reform. Both
Ministries have high-level experts, and have in the past demonstrated their commitment to
conduct sector reforms satisfactorily. Furthermore, a technical reform steering committee will
be responsible for monitoring the programme.
5.1.2
Disbursement and flow of funds: The budget support will be disbursed in two
tranches, each subject to fulfilment of the conditions retained. Upon Government’s requests
for tranche disbursement, the Bank will deposit the agreed amounts in the foreign currency
account opened in the Central Bank of Morocco (Bank Al Maghrib) by the Treasury. The
Borrower will take appropriate steps to ensure that the equivalent of the funds deposited in the
Central Bank account in foreign currency is transferred in local currency to the Treasury current
account for the national budget. Bank disbursements will be made in 2013 and 2014.
5.1.3
Fiduciary Arrangements
5.1.3.1
Morocco’s fiduciary risk is considered to be moderate. Recent diagnoses of
public finance management in Morocco (PEFA 2009 and more recent reviews under other
programmes) indicate a satisfactory performance, and the planned improvements should result
in a low residual risk level. Concerning the health sector and the programme, the initial
fiduciary risk is considered to be high, but the mitigation measures recommended are expected
to reduce it to a moderate level at the end of the operation (see Technical Annex II).
5.1.3.2
Resources will be used in accordance with national regulations on public
finance. The MEF will be in charge of resource management. It will ensure that budget heads
(grants, special Treasury accounts, etc.) or any other resources required for implementation of
the programme are included in the 2013 and 2014 Finance Laws for the Ministry of Health,
the Prime Minister’s Office, the Ministry of Interior, the Ministry of Employment, the Ministry
for the Modernization of Public Administration and other subsidized public establishments
(ANAM, CNOPS, CHU, SEGMA, Institutes, Centres, National Laboratories and the National
Pharmacy) concerned with the implementation of PARCOUM III. The entire public
expenditure chain will be used on the basis of existing conducive conditions and subject to
Government’s commitment to pursue public finance management reforms. Financial sector
governance will be strengthened by implementing measures relating to RAMED governance,
improving access to health care, enhancing visibility regarding BMC financing, and
strengthening accountability by citizens (see Technical Annex).
5.1.3.3
Procurement Arrangements: Since the loan is a sector budget support, it does
not involve direct procurement. The support resources will be paid into the Public Treasury
(hence fungible with the national budget) which will transfer them through the usual
mechanisms to the Ministry of Health and the institutions concerned, which will in turn use
them for the procurement of their requirements in accordance with the national procurement
procedures in force. The review of the national public procurement system by the Bank in
18
August 2011 revealed that Moroccan procurement regulations are largely consistent with the
Bank’s policy standards, except for some divergences which were the subject of dialogue
between the Bank and Moroccan authorities.
5.1.4
Audit Arrangements
5.1.4.1
The internal audit of PARCOUM III will be based on the national internal expost control mechanism. The audit will be conducted on an annual basis and for the duration
of PARCOUM III (2013-2014) by the General Inspectorate of the Ministry of Health and IGF
on the basis of their respective mandates, and will focus on ADB support financial flows and
performance regarding the implementation of programme measures for each financial year. The
deadline for submitting the financial flows and performance audit report by the IGF to the Bank
will be six months following the end of each financial year.
5.1.4.2
The Court of Auditors of Morocco will conduct the external audit of the use of
PARCOUM III resources for 2013 and 2014 during the review of the Audited Budget
Law. The Court’s reports (compliance statement) will be published on schedule, in accordance
with the Organic Law. The Court may also verify the implementation status of the measures
and achievement of the performance objectives and indicators of PARCOUM III.
5.2
Monitoring and Evaluation Arrangements
5.2.1
Responsible institutions: The Ministry of the Economy and Finance will be
responsible for strategic coordination of PARCOUM III, while the Ministry of Health will
ensure its operational coordination. However, other Ministries and agencies will be involved
in the programme implementation, in particular the Prime Minister’s Office, the Ministry of
Interior, the Ministry of Employment, the Ministry for the Modernization of Public
Administration, ANAM, CNOPS and CNSS. These institutions will report directly to the InterMinisterial Reform Committee coordinated by the Prime Minister’s Office.
5.2.2
Monitoring System: PARCOUM III implementation will be monitored and
coordinated in accordance with the Bank’s rules and on the basis of the matrix of
measures adopted together with the Government. The Bank and the EU will coordinate
supervision missions, which will be undertaken at least twice a year in May and October to
review the PARCOUM III monitoring framework, annual progress reports, the analysis of the
recommendations made during the first annual supervision mission, and the decision to make
disbursements for year n +1. The Bank Office in Morocco will play a key role in programme
monitoring and sector dialogue.
5.2.3
Information System and Reporting and Dissemination Mechanisms:
Implementation will be monitored through annual sector strategy implementation status
reports and financial reports submitted to the Bank by the Government. A completion
report will be prepared together with the Government in 2015. Impact assessment should also
help to test the establishment of mechanisms for assessing citizen participation, which will be
financed by the ADB (trust fund).
19
6.
LEGAL DOCUMENT AND AUTHORITY
6.1
Legal Document
6.1.1
A loan agreement for financing of the programme will be signed between the
Kingdom of Morocco and the Bank.
6.2
Conditions for Bank Intervention
6.2.1
Conditions precedent to Board presentation: The presentation of the programme
to the Bank’s Board of Directors shall be subject to fulfilment, by the Moroccan Authorities, of
Measures 1 to 4 outlined in Table 4.
6.2.2
Conditions precedent to effectiveness of the Loan Agreement: Effectiveness of
the Loan Agreement shall be subject to fulfilment of the conditions set forth in Section 12.01
of the General Conditions Applicable to Bank Loan Agreements and Guarantee Agreements.
6.2.3
Conditions Precedent to Disbursement
6.2.3.1
First Tranche: The disbursement of the first loan tranche (EUR 70 million)
shall, in addition to effectiveness of the Loan Agreement, be subject to fulfilment, by the
Borrower and to the satisfaction of the Bank, of the following condition precedent: provide the
Bank with evidence of the opening of an account in foreign currency in Bank Al-Maghrib to
receive the loan resources. The two-tranche option helps to sequence programme measures
(particularly conditions) and better assess the impact of reforms. The amounts earmarked
correspond to very short-term financing requirements for implementing the reform and, if need
be, resources needed to pursue the efforts initiated.
6.2.3.2
Second Tranche: The disbursement of the second loan tranche (EUR 45 000
000) shall be subject to fulfilment, by the Borrower and to the satisfaction of the Bank, of
conditions precedent 5 to 7 set forth in Table 4.
6.3
Compliance with Bank Group Policies
6.3.1
The programme is consistent with applicable Bank policies, including Bank
operational guidelines for programme support operations. No exception is requested.
20
7.
RISK MANAGEMENT
Table 6
Risks and Mitigation Measures
Risks
Better health insurance coverage
does not result in increased
demand for health care
Health care delivery cannot keep
pace with new demand on a
relatively short-term basis
Level
Moderate
Mitigation Measures
Sensitization campaigns carried out by ANAM and MS; visibility
is ensured by the King’s commitment.
Moderate
Many donors are involved in the health sector, and PARCOUM III
provides for measures to improve the quality of care. The
Government has also allocated budgetary resources for the sector.
Insufficient visibility regarding
resources allocated for the
reform
Delays in identification of
RAMED
members
and
distribution of cards
The mobilization of health care
providers and pharmacists to
work in disadvantaged regions
falls short of expectations.
The initial sector fiduciary risk
assessed by the Ministry of
Health is very high.
Moderate
Two conditions relating to the Social Cohesion Support Fund are
included in the programme.
Moderate
Measures to improve the processing of files and the targeting
system are adopted.
High
A series of incentives are adopted to attract them to disadvantaged
regions.
Very high/
Moderate
However, it will be mitigated to an overall moderate level to allow
for implementation of sector support, subject to consideration of
mitigation measures aimed primarily at ensuring visibility
regarding BMC financing and improving service availability
(Measures A.1.2 and A.3.1), as well as implementing measures
related to the LOF, the programme budget and capacity building
of IGMs.
8.
RECOMMENDATION
PARCOUM III will support the establishment of social protection and contribute to
improving the health status of the population. Management hereby recommends that the
Board of Directors approve the proposal to grant a EUR 115 million loan to the Kingdom of
Morocco for implementation of the programme in accordance with the purposes and under the
conditions set forth in this report.
21
Appendix 1
Page 1/3
Appendix 1: Development Policy Letter
KINGDOM OF MOROCCO
The Minister
To The President of the African Development Bank Group
B.P. 323 – TUNIS BELVEDERE
1002 – TUNISIA
- Tunis Subject: Basic Medical Coverage Reform Support Programme (PARCOUM III)
Mr. President,
Further to the request made by the African Development Bank mission that visited
Morocco from 8 to 19 April to appraise the third phase of the Basic Medical Coverage Support
Programme (PARCOUM III), I have the honour to forward herewith the Health Sector Policy
Letter outlining the main thrusts of the Health Strategy for the 2012-2016 period.
While counting on your support for a favourable consideration of this request, please
accept, Mr President, the assurances of my highest consideration.
Copy for information to:
- The African Development Bank Resident Representative in Morocco
- Rabat -
Appendix 1
Page 2/3
Sector Policy Letter to the African Development Bank
Aware of the people’s aspirations to quality health care and services, the need to entrench the
right to health services as a basic principle of human rights, improve all aspects of health and
redress all imbalances that have characterized the health sector, the Ministry of Health has
prepared an action plan for the 2012-2016 period in efforts to rebuild the national health system.
These efforts are consistent with the 2012-2016 health policy thrusts outlined in the
Government’s general policy statement that was presented before Parliament in January 2012,
and take into account Royal Guidelines underscoring the importance of socio-economic
projects. The bases of this policy are also rooted in the Constitution as it is in line with Articles
31 and 34 of Morocco’s new Constitution which underscore good governance and
accountability.
Since 2002, the African Development Bank (ADB) has supported the Moroccan Government,
particularly the Ministry of Health, in one of the key projects concerning the reduction of
inequalities and social inclusion, that is basic medical coverage (BMC).
The Bank’s support began with the first phase, which helped to establish the BMC legal
framework, particularly through the preparation of Law No. 65-00 to institute the Basic
Medical Coverage Code. This phase covered the 2002-2006 period and benefited from a EUR
80 million financial support.
The second phase of the Bank’s support (PARCOUM II) helped to consolidate the
achievements of the first phase and launch the Medical Assistance Scheme (RAMED) for the
disadvantaged segment of the population. PARCOUM II spanned the 2008-2012 period and
benefitted from a EUR 70 million financial support.
The third phase of ADB’s support (PARCOUM III) is in harmony with the new Country
Strategy Paper (CSP) for the 2012-2016 period. It is based on consensus on the need to target
inclusive growth in line with Government’s priorities, while promoting synergy and
complementarity with the activities carried out by other development partners.
To that end, two thrust areas have been identified, namely: (1) strengthening of governance
and the institutional framework; and (2) support for infrastructure development and social
inclusion.
For its part, the Ministry of Health has initiated a new strategy for the 2012-2016 period, which
has enabled it to consolidate the achievements made so far, and address the challenges of the
new health system. This new strategy focuses on eleven priority programmes:
1.
2.
3.
4.
5.
6.
7.
Extension of CHI and Consolidation of the Generalization of RAMED;
Implementation of the National Medical Emergency Management Plan;
Consolidation of the Plan to Accelerate the Reduction of Infant and Maternal Mortality;
Improvement of Access to Drugs and Pharmaceutical Products;
Improvement of Health Sector Governance;
Improvement of Reception and Health Service Delivery in Public Hospitals;
Implementation of the Plan for the Organization of Health Care Sectors and the
Introduction of Family Medicine;
8. Development of Basic Health Care, particularly in Rural Areas;
9. Consolidation of the National Health Plan for People with Special Needs;
10. Strengthening of Health Surveillance and Disease Control; and
11. Strengthening of Supervision by Qualified Human Resources.
Appendix 1
Page 3/3
In this connection, PARCOUM III will serve as a link between the MS strategy and the Bank’s
CSP, thus helping to mobilize the Bank’s expertise while remaining consistent with sector
priorities. To that end, three support thrusts, each with specific objectives, have been identified.
Provisional Programme Thrusts and Objectives
Thrust 1:
O1 :
O2 :
Thrust 2:
O1 :
O2 :
O3 :
Thrust 3:
O1 :
O2 :
O3 :
BMC steering and sustainability
Strengthen reform steering and governance
Ensure the adequate and sustainable financing of BMC
Extension of BMC
Consolidate the generalization of RAMED
Extend CHI to self-employed workers
Extend and consolidate CHI for salaried employees
Regulation and delivery of health care
Improve the availability of resources for better quality health
care
Stimulate and streamline demand for health care
Strengthen citizen participation and accountability
Corresponding Priority
Programmes (PP)
PP1
PP5
PP11
PP1
PP4
PP2
PP4
PP6
PP7
PP8
In addition to the PARCOUM Programme, the Ministry of Health also wishes to mobilize
ADB’s support for the establishment of the Geographic Information System (GIS) which will
be an important planning tool to ensure more equitable allocation of resources to the regions
based on a thorough assessment of the relative needs of the people for greater equity in the
distribution of health care delivery. The objectives of this project are to:

improve availability and access to information related to health care delivery for health
professionals, Moroccan citizens and investors in the health sector;

enable health professionals to share the same health information and ensure reliability
of data at all levels of the health system (public and private) so as to allow for equitable
distribution of resources between urban and rural areas, between regions and within
each region;

provide policy makers with a rational tool for decision making (evaluation, planning
and programming) based on each territorial entity, taking into account the
(geographical, economic and cultural) realities on the ground;

improve the skills of health professionals likely to use health care delivery planning
tools.
Dr. Abdelai Belgiati Alaoui
Secretary-General
Appendix 2
Page 1/3
Appendix 2: Matrix of Medical Coverage Reform Support Programme – Phase 3 Reform Measures
NB: Triggers are in bold and measures in italics are common with the European Union.
MEDIUM-TERM
OBJECTIVES
MEASURES AND INSTITUTIONS IN CHARGE
MEASURE 2013
MEASURE 2014
INSTITUTION
OUTPUT INDICATORS
2013
2014
THRUST 1: STEERING AND FINANCING OF BASIC MEDICAL COVERAGE
A.1.1 Strengthen the steering and governance of basic medical coverage
Prime Minister’s
At least two meeting
Strengthen the
Submission of InterCorrespondence
Extension to all
Office, Interreports are submitted
reform steering and
Ministerial Committee
between the MEF
stakeholders and
Ministerial
governance
biannual meeting reports
and the Prime
strengthening of the
Committee
mechanism
Minister’s Office are
Inter-Ministerial
forwarded.
Committee on
Strategic Reform
Orientations and
Decisions
Prime Minister’s
At least three meeting
Establishment of the
Office, Ministry
reports are submitted
Programme Technical
designated by the
Committee chaired by
Head of
the Prime Minister’s
Government
Office or Ministry
designated for that
purpose by the Head of
Government
Improve
RAMED
management
Presentation of the Plan
for Improvement of
Institutional
Arrangements and
Tools for RAMED
Management to the
Inter-Ministerial
Committee by the
Technical Committee
A.1.2 Ensure sustainable financing of basic medical coverage
Programme
Steering Committee
Ensure visibility
regarding BMC
financing
MEF
Mobilization of
resources allocated to
RAMED
Transfer, by MEF, of
resources from the
Social Cohesion
Support Fund to
RAMED
The resources
allocated to RAMED
are mobilized
MEANS OF VERIFICATION
OUTCOME
INDICATORS
2013: Correspondence
2014: Reports
2013: Letter by the Head of
Government establishing the
Technical Committee and
specifying its role and composition
2014: Report
Submission of the
Plan for Improvement
of Institutional
Arrangements and
Tools for RAMED
Management to the
Inter-Ministerial
Committee
2014: The Committee’s agenda
and the Improvement Plan
Resources are
transferred to
RAMED
2013: Submission: (i) of FCS’s
2013 Provisional Employment
Programme; (ii) decisions granting
resources to CHUs stating that
they are intended for RAMED
beneficiaries; and (iii) copies of
statements issued by TGR showing
the balance of the FCS as at 31
December 2012 and 31 July 2013
2014: Submission of FCS’s 2014
Employment Programme endorsed
by the Ministry of the Economy
and Finance and evidence of the
transfer to RAMED of the
resources indicated in the 2013
Programme
Share of household
expenses in total health
expenditure
2014: 48% (53% in 2010).
Source: CNS; MS
Household Expenditure
Survey
Appendix 2
Page 2/3
MEDIUM-TERM
OBJECTIVES
MEASURES AND INSTITUTIONS IN CHARGE
MEASURE 2013
Develop a mediumterm financing
framework
Formulation of the
2014-2016 programme
budget (guidelines
issued by MS)
MEASURE 2014
INSTITUTION
Submission of the health
sector financing strategy
to MEF
MEF, DPRF (MS)
Signing of 16 programme
contracts with the health
regions
DPRF (MS)
OUTPUT INDICATORS
2013
The guidelines are
signed
2014
MEANS OF VERIFICATION
The strategy is
adopted by the MS
and submitted to MEF
Letter of transmittal to MEF and
validated strategy
The 16 health regions
have signed
programme contracts
2013: Transmission of guidelines
OUTCOME
INDICATORS
2014: Transmission of programme
contracts
THRUST 2: EXTENSION OF BACIC MEDICAL COVERAGE
A.2.1 Strengthen the implementation of the Medical Assistance Scheme (RAMED)
Improve the
processing of
registration files
Interconnection of 800
related administrative
services
Ministry of Interior
800 related
administrative
services are
interconnected
MS
Review of the targeting
system included on the
Inter-Ministerial
agenda of the InterCommittee
Ministerial committee
A.2.2 Develop medical coverage for elf-employed socio-professional categories
Report of the Ministry of Interior
2013: Submission of the validated
actuarial study
2014: Agenda of the InterMinisterial Committee
Improve the RAMED
targeting system
RAMED actuarial study
validated by MS
Define a strategy for
coverage of selfemployed workers
Proposal of scenarios
for coverage of selfemployed workers
Presentation of a draft
strategy for coverage of
self-employed workers to
the Reform Steering
Committee
MS
A scenario for
coverage of selfemployed workers is
validated
The draft strategy for
coverage of selfemployed workers is
presented to the
Steering Committee
2013: Cover letter of proposed
scenarios for coverage of selfemployed workers to the Prime
Minister’s Office by MS
2014: Submission of the first draft
strategy for coverage of selfemployed workers
Extend medical
coverage for selfemployed workers
Inclusion of canoe
builders in the CNSS
Presentation, by the
Council of Ministers, of
the bill on coverage of
students
CNSS
Canoe builders are
included in the
CNSS
The bill on coverage
of students is
presented to the
Council of Ministers
2013: Agreement signed with the
CNSS
Ministry of
Employment
% eligible persons
registered with RAMED
2013: 85%
2014: 93%
Source : ANAM
Self-employed workers
affiliated to the CHI
scheme
2014: 200 000
Source : CNSS Annual
Balance Sheet
2014: Cover letter of the bill to the
SGG, including the bill
THRUST 3: REGULATION AND DELIVERY OF HEALTH CARE
A.3.1 Improve availability and quality of services
Improve availability
of services
Adoption of regulations
governing the
deconcentration of
human resource
management
Submission, to the SGG,
of the draft decree on the
status of private sector
physicians and dental
surgeons registered with
the MS
DRH, DRC (MS)
Submission, to the SGG,
of the bill on health map
DRC, DPRF
The instrument
relating to the
deconcentration of
human resource
management is
adopted by the MS
The decree relating to
physicians and dental
surgeons is submitted
to the SGG
2013: Submission of the
instrument relating to the
deconcentration of human resource
management
2014: Submission, to the SGG, of
the draft decree relating to the
status of private sector physicians
and dental surgeons registered with
the MS, as well as a copy of the
cover letter
The delegation of signing
authority to regional
directors is effective
The bill on health
map and regional
health care delivery
Cover letter of the bill to the SGG
and the bill
Number of inhabitants per
public sector physician
2012 : 2725 (2500 in 2015)
Appendix 2
Page 3/3
MEDIUM-TERM
OBJECTIVES
Improve the quality of
human resources
MEASURES AND INSTITUTIONS IN CHARGE
MEASURE 2013
Draft instrument
subjecting promotion to
further training
MEASURE 2014
and regional health care
delivery systems
Adoption of four rules of
“good practices” by the
Ministry of Health
INSTITUTION
MS
ANAM
OUTPUT INDICATORS
2013
The draft instrument
on further training is
transmitted to the
SGG
2014
systems is submitted
to the SGG
Four rules of good
practices are adopted
MEANS OF VERIFICATION
OUTCOME
INDICATORS
Source :MS
Cover letter of draft decree to the
SGG and the draft decree.
Documents on rules of good
practices
A.3. 2 Streamline the use of health care services
Ensure compliance
with health care
procedures
Adoption of the
coordinated project for
the medical follow-up of
chronic diseases by the
Board of Directors of
ANAM
ANAM
The coordinated
project for the
medical follow-up of
chronic diseases is
adopted by the Board
of Directors of ANAM
Minutes of the ANAM Board of
Directors’ meeting
Streamline the use
and facilitate access
to drugs
Submission, to the SGG,
of the draft decree
relating to the terms and
conditions for fixing the
prices of drugs sold to the
public
DRC, DMP (MS)
The draft decree
relating to the terms
and conditions for
fixing the prices of
drugs sold to the
public is submitted to
the SGG
Cover letter of draft decree to the
SGG and the draft decree
Publication of the
RAMED barometer
DHSA
The RAMED
barometer is
published
2013: Submission of the evaluation
report
2014: Submission of the RAMED
barometer
% of CHI policyholders
enjoying the services of a
family doctor
2015 : 40%
Source : ANAM
A.3.3 Strengthen accountability
Promote citizen
participation
Evaluation of the pilot
project for the
management of
complaints in hospitals
ANAM
The evaluation
report is available
% of households which
think that health services
have improved
2014: 40% (23% in 2012)
Source: HCP
Appendix 3
Page 1/1
Appendix 3: IMF Press Release
The IMF Executive Board Completes the First Review Under Precautionary and
Liquidity Line Arrangement for Morocco
Press Release No. 13/38
February 4, 2013
The Executive Board of the International Monetary Fund (IMF) on February 1, 2013 completed the
first review of Morocco’s performance under an economic program supported by a two-year
Precautionary Liquidity Line (PLL) arrangement and reaffirmed Morocco’s continued qualification to
access PLL resources.
The PLL was approved on August 3, 2012 in an amount equivalent to SDR 4,117.4 million (about
US$6.3 billion, 700 percent of quota, see Press Release No. 12/287). The access under the arrangement
in the first year is equivalent to SDR 2.4 billion (about US$3.6 billion, or 400 percent of quota), rising
in the second year to cumulatively SDR 4.1 billion (about US$6.3 billion).
The PLL arrangement will continue to support the authorities’ home-grown reform agenda aimed at
achieving higher and more inclusive economic growth by providing a useful insurance against external
shocks. The PLL was introduced to meet more flexibly the liquidity needs of member countries with
sound economic fundamentals and strong record of policy implementation but with some remaining
vulnerabilities.
The IMF’s Executive Board welcomed the authorities’ intention to continue treating the arrangement
as precautionary.
Following the Board’s discussion, Ms. Nemat Shafik, Deputy Managing Director and Acting Chair,
issued the following statement:
“Over the past decade, Morocco’s overall sound macroeconomic policies helped deliver solid growth,
low inflation, and poverty reduction, despite continued high youth unemployment. This extended
period of sound economic performance has been recently challenged by a worsening of the external
environment and a below-average harvest, even though the non-agricultural GDP growth remained
robust and inflation low. Against this backdrop, the authorities’ economic strategy is built appropriately
on fiscal consolidation, structural reforms and prudent monetary and financial policies. Sustained
implementation will be key to rebuilding buffers, preserving macroeconomic stability and achieving
stronger and more inclusive growth.
“The arrangement under the Fund’s Precautionary and Liquidity Line (PLL), which the authorities
intend to continue to treat as precautionary, has provided Morocco with an insurance against external
risks and supported the authorities’ economic strategy.
“The authorities’ fiscal strategy, including the 2013 budget, is in line with their commitment to
maintain fiscal sustainability and support external adjustment. As part of this strategy, it will be
important to move ahead with the reforms of the general subsidy system and the pension system and
to better target social protection. Fiscal space needs to be preserved to support higher and more
inclusive growth.
“Efforts to strengthen competitiveness and better equip the economy to respond to external shocks are
a priority. The planned fiscal consolidation and structural reforms, such as those to improve the
business climate and professional training, will help underpin external sustainability. Morocco is
encouraged to move toward greater exchange rate flexibility to enhance external competitiveness and
the economy’s ability to absorb shocks, in coordination with other macroeconomic and structural
policies.
“Over the past decade, substantial progress has been made in improving social indicators. However,
sustained further efforts are still needed to increase growth and make it more inclusive, notably by
boosting employment, in particular of the youth, reducing income inequalities, and increasing access
to health care and education.”
IMF External Affairs Department
Appendix 4
Page 1/1
Appendix 4: Recent Key Economic Indicator Trends and Projections, 2010-18
2010
Production and Prices
Real GDP
Real Non-agricultural GDP
Consumer Prices (End of Period)
Consumer Prices (Period Average)
Investment and Savings
Gross Capital Formation
Of which: Non-public
Gross National Savings
Of which: Non-public
2011
2012 2013 2014 2015 2016 2017 2018
(Annual Percentage Change)
3.6
5
3.2
4.9
5
4.5
2.2
0.9
2.3
1
0.9
1.3
(As a Percentage of GDP)
4.5
4.5
2.5
2.4
4.8
4.7
2.5
2.5
5
5
2.5
2.5
5.4
5.4
2.5
2.5
5.7
5.8
2.6
2.6
5.8
5.9
2.6
2.6
35
36 36.1
31.2 31.5 31.9
30.9 27.9 27.3
28.9 28.5 28.4
(As a Percentage of GDP)
36.6
31.8
30.4
29.4
37.4
31.9
31.7
29.5
37.8
32.1
32.6
29.5
38.2
32.4
33.4
29.7
38.4
32.6
33.9
29.9
38.8
32.9
34.3
29.9
Public Finance
Revenue 1 /
27.5 27.8 27.7 28.2 28.3 28.2 28.2 28.1 28.2
Expenditure
31.9 34.6 33.8 32.9 32.4 31.7 31.2 30.7 30.6
Budget Balance
-4.4 -6.8
-6.1 -4.7 -4.1 -3.5
-3 -2.7 -2.4
Primary Balance (Excluding Grants)
-2.3 -4.7
-3.8 -3.4 -2.7
-2 -1.5 -1.1 -0.8
Total Public Debt
51.3 54.4 58.2
59
59 58.4
57 55.2 53.3
(Annual Percentage Changes, Unless Otherwise Indicated)
Monetary Sector
Credit to the Private Sector 2
7.5
9.9
7
8
...
...
...
...
...
Broad Money
4.8
6.5
3.3
7.9
...
...
...
...
...
Broad Money Velocity
0.9
0.8
0.9
0.8
...
...
...
...
...
3-Month Treasury Bill Rate (Period
3.4
3.5
3.2
...
...
...
...
...
...
Average, as a Percentage) 3 /
(As a Percentage of GDP, Unless Otherwise Indicated)
External Sector
Exports of Goods (USD, Percentage
26.7
21
-3.5 10.4
8.1
5.6
6.5
6.9
7.1
Change)
Imports of Goods (USD, Percentage
7.7 25.4
-1.6
5.9
5
5.4
5.9
6.8
7.6
Change)
Trade Balance
-16.4 -19.6
-20 -18.8 -17.8
-18
-17
-17
-17
Current Account Balance, Excluding
-4.4 -8.4
-8.9 -7.9 -6.8 -6.4 -5.8 -5.4 -5.3
Official Transfers
Current Account Balance, Including
-4.1
-8
-8.8 -6.3 -5.7 -5.3 -4.8 -4.5 -4.5
Official Transfers
Foreign Direct Investments
0.8
2.3
2.2
2.8
2.8
2.9
3
3
3
Total External Debt
24.7 23.6 26.4 27.5 27.1 26.6 25.9 24.6 23.8
Gross Reserves (in USD billion)
23.6 20.6 17.5 18.4 18.8 19.7 21.3 22.6 24.6
In Months of Imports of Goods and Services
5.7
5.1
4.1
4.1
4
4
4
4
4.1
in the Following Year
Percentage of Short-term External Debt
1 546 1 222 1 037 1 091 1 112 1 168 1 259 1 339 1 455
(Based on the Remaining Maturity)
Memorandum Item:
Nominal GDP (in USD billion)
90.8 99.2 97.5 105 112 120 130 141 153
Unemployment Rate (Percentage)
9.1
8.9
…
...
...
...
...
...
...
Net Imports of Energy Goods (in USD
-8.1 -11.2 -11.8 -11.5 -11.4
-11
-11
-11
-11
billion)
Sources: Moroccan authorities and IMF estimates.
1. Including changes in the balance of other special Treasury accounts.
2. Including credit to public enterprises.
3. Latest data for 2012.