Morocco COVID-19 response: A fragile health system and the deteriorating situation

Learning from its European neighbors, Morocco imposed drastic measures from the initial stages of the COVID-19 outbreak to try to contain its spread. The strategy worked for a few months but the cases have surged after mid-June. In this situation, Morocco, which is already strained with limited resources, should ensure timely availability of reliable healthcare data for informed evidence-based decision making and efficient resource allocation.

Morocco was particularly vulnerable to the COVID-19 pandemic due to its geographical limitation of sharing a land border with Spain along with a weak health system that many feared would collapse in case of a wide contamination wave. But the country also had the good luck of witnessing other countries’ responses before drafting their own as the first COVID-19 case in Morocco was reported only on March 2. Till then, its neighbor Spain had already recorded more than 3,000 cases while Italy’s first lockdown covering 10 municipalities started as early as February 21.

Learning from European neighbors, Morocco adopted drastic measures from the initial stages of the COVID-19 outbreak to try to contain its spread. On March 20th, the country enacted a state of emergency after recording only 77 cases. As part of the measures, public events were suspended, strict restrictions were imposed on movement within cities, and inter-city as well as international travel.

The strategy worked and Morocco was lauded for its effective response in handling the pandemic. The World Bank on June 16 praised the country for one of the lowest fatality rates saying, “Morocco managed to contain a wider spread of the epidemic, sparing the health system and its 9,200 public sector doctors from severe stress.”

But the next few weeks changed opinions as COVID-19 cases in the country rose manifold from around 9,000 in mid-June to 86,686 on September 14.

Morocco’s COVID-19 response

After recording just 77 cases, Morocco declared a state of emergency on March 20 acknowledging the growing threat of the COVID-19 outbreak. Morocco’s armed forces and police were tasked to enforce strict measures.

The state of emergency in Morocco meant that citizens required special authorization from local authorities to go out to public spaces. Permissions were being granted for specific causes which included employees of the essential sector going to their workplaces and people going out to buy groceries or medicines or seeking healthcare.

Apart from the inter-country restrictions, Morocco also implemented one of the world's strictest border lockdowns by abruptly suspending all international passenger flights and passenger ships to and from its territory on March 15.

While many countries other closed borders as well to try to stop the outbreak, Morocco went farther and barred even its own citizens from coming back to Moroccan soil in hopes of reducing the spread of the virus and avoid and overwhelming its under-prepared health system. This meant that tourists scrambled to get out and Moroccans abroad struggled to come home.

The first setback for Morocco was supposedly its jails where multiple outbreaks were detected. Dozens of prison staff were infected with the disease in April-May and the government took several measures including pardoning thousands of inmates to protect staff as well as remaining inmates.

Several other outbreaks were recorded in the country over the following months. In June, an outbreak in factories of Kenitra city infected more than 500 worked and led to a judiciary investigation. Another outbreak was detected at Jorf Lasfar port that led to the creation of a field hospital near the region.

In early July, lockdown measures were reimposed in Safi after new clusters were detected in fish canning factories. Key cities like Tangier and Marrakech have also seen restrictions reimposed after a surge in cases.

As mentioned earlier, many experts and Moroccans were skeptical about the ability of the country’s public health infrastructure in handling the pandemic. According to a survey by the Moroccan Institute for Policy Analysis (MIPA), 74 percent of respondents distrust the hospitals' capacity to cope with COVID-19. But the rapid actions of the government instilled confidence among citizens as 77 percent of Moroccan respondents expressed their satisfaction with the measures taken by the government even though 58 percent of Moroccans were not confident in the government’s capacity to manage the pandemic.

When the outbreak began, Morocco was among the countries with the lowest hospital bed capacity equipped with just 1.1 beds per 1,000 people. Other indicators regarding the health workforce were also concerning at just 0.68 physicians and 0.84 nursing and midwifery density per thousand people in the public sector. Acknowledging the limitations, Morocco worked hard to build up capacity by setting up several field hospitals.

Within the first two weeks of announcing a national emergency, Morocco’s Royal Armed Forces (FAR) built a military field hospital in Benslimane near Casablanca. On April 20, another field hospital was built at a 16,000 sq mt. site and equipped with 700 beds became ready to handle COVID-19 patients in Casablanca. In late June, another field hospital was set up in Kenitra to handle the increased load linked to outbreaks at fruit farms and packaging factories. El Jadida also got a field hospital while a few similar projects are in pipeline for hand-hit Marrakesh as well as Casablanca.

These hospitals were thoroughly utilized to handle the patient burden during the pandemic. But as the cases surge, both healthcare staff and the infrastructure are being pushed to limits and most cases are concentrated to only a handful of cities, making management more difficult and increasing the role of a robust, integrated health information system that helps in guiding policy decisions to ensure most optimum resource allocation and load distribution.

Risk communication

According to a situational analysis by The Partnership for Evidence-Based Response to COVID-19 (PERC), all Moroccans are aware of the existence of COVID-19 but many people hold misperceptions about the pandemic. The analysis said that 58 percent of people believed that “hot climates prevent spread” of infection while 48 percent believed that consuming vitamin C and lemon can prevent it. As much as 39 percent believed that the pandemic is “a punishment from God” while 20 percent believed the bioweapon theory.

As the virus started spreading far and wide in Morocco after the initial success of a few months, authorities have partially blamed people violating lockdowns and not following protective measures. While commemorating the 67^th anniversary of the Revolution of the King and the People, King Mohammed VI called out violators by saying, “there are people who claim that this epidemic does not exist. There are those who believe that the lifting of the lockdown means the epidemic is over, while others are behaving in an unacceptably lax and careless way.”

A former health minister of Morocco, Anass Doukkali, wrote in an op-ed (https://www.maroc-hebdo.press.ma/covid-19-ces-temps-difficiles-) that even though the lockdown phase was more or less well-managed, the process to lift restrictions was marred by “incoherent communication, confused messaging … and some decisions that were hasty and poorly explained” that resulted in people paying less attention to protective measures of the government.

Slow contact tracing and low testing

COVID-19 cases have been surging in Morocco ever since the country starting easing lockdown measures. This is a major setback for the country that was once believed to have brought the outbreak under control. With the help of a strict lockdown, the North African country reduced new cases to just 40 a day but daily cases have since increased to 2,238 on September 13.

This sharp surge in cases is largely being attributed to the “rushed” lifting of movement restrictions in the country. Local health experts have also lamented shortcomings of the country’s mass testing and contact-tracing measures, claiming that implementation has been ineffective and slow.

In a videoconference of health experts of the country, Afif Moulay, the president of the Moroccan Medical Sciences Society, said that “we need to administer more tests to identify cases early and treat them before they reach critical stages.” While Morocco has been consistently working to increase its testing capacity, the experts said that most COVID-19 cases in the country are still tested late.

Experts in the videoconference also raised concerns about the effectiveness of contact-tracing in the country, according to reports. They explained that contact-tracing and testing of an infected person’s contacts take 7 or more days but by then, many of the newly infected people are already in an advanced stage of infection.

Many small outbreaks scattered across Morocco are being detected and these could grow quickly if not monitored effectively and closely. Containing these outbreaks would heavily depend on how the government improves contact-tracing and testing efforts.

Overburdened health system

As COVID-19 cases in Morocco surge, authorities are having a hard time in managing the burden on healthcare facilities, particularly in the iconic tourist city of Marrakech. Doctors and other healthcare staff have been protesting about the chaotic state of hospitals in the city. Pictures recently circulating online have shown COVID-19 patients in Marrakech lying on the floor of crowded hospitals.

To protest against the situation, healthcare workers from the main Ibn Zohr hospital observed a sit-in on August 17 to denounce the situation of the facility and call the Health Ministry for action. A statement purportedly by health professionals of the hospitals even called to end COVID-19 services given the “lack of safety conditions.” A media report by Marrakech-based media outlet Kech 24 had described the situation in Ibn Zohr as “abnormal,” claiming that the hospital lacks the “minimum working conditions” that can ensure the safety of healthcare workers.

On August 19, Health Minister Khalid Ait Taleb visited the city to take stock of the situation and announced a new field hospital to handle the increasing cases.

While late testing having been identified as one of the major factors in COVID-19 complications, some reports have even lamented the unhygienic conditions at testing centers. A recent report explaining the experience of a potential COVID-19 carrier of getting tested detailed the delay as well as the dangerous conditions as the “ground was full of waste from the test kits, plus tissue paper and used gloves.”

Morocco health system

In Morocco, the delivery of healthcare services relies on the public as well as private healthcare providers, and the main cities are equipped with more sophisticated service providers. All Moroccans are legally entitled to free public primary healthcare services but geographic barriers and unequal distribution of health services raise concerns about unequal access. Healthcare services delivered by public secondary and tertiary hospitals, on the other hand, involve payments and private providers are believed to be better equipped.

The health system in the country also suffers due to huge resource gaps, especially with respect to human capital. There are only 0.68 physicians and 0.84 nursing and midwifery density per thousand people in the public sector.

Morocco’s spending on health remains low despite increased budget in recent years. Investments in healthcare remain low at less than 6 percent of GDP while out-of-pocket expenses are at a staggering 54 percent.

The share of public health expenditure in total government expenditure suggests that health is “slightly less a priority for the Government of Morocco” than the governments of comparator countries, according to a report by World Bank in 2018.

Over the years, Morocco has launched several initiatives to establish universal health coverage and improve the quality of healthcare in the country. In 2002, the government launched a health financing reform to make progress on the aim of establishing universal health coverage. The reform included subsidized social health insurance for the poor and vulnerable groups (Régime d’Assistance Médicale-RAMED) and non-subsidized compulsory health insurance schemes for salaried workers (Assurance Maladie Obligatoire). RAMED has been widely appreciated and covers millions of poor Moroccans but despite these efforts, only 68.8 percent of the population was insured in 2019 with significant gaps among people living in urban and rural areas.

The geographical barriers are noticeable in health indicators of Morocco which remain well behind the levels of comparable countries in the region. These barriers highlight inequities in access and quality of healthcare as well as in the allocation of resources.

To address such shortcomings and to improve quality and accountability, Morocco needs a robust, integrated health management information system to ensure informed decision-making with the timely availability of high-quality data.

Health information system

Morocco has been working with the World Bank to develop a health management information system (HMIS). In 2015, the Bank launched a project ‘Improving Primary Health in Rural Areas Program-for-Results’ to help the Moroccan government improve its healthcare system.

Apart from the goal of improving primary health in rural areas of Morocco, the project was also aimed at improving governance in healthcare. Stakeholders acknowledged that Morocco’s HMIS was siloed and fragmented lamented with poor integration of central data and ineffective, slow data collection mechanisms. These shortcomings heightened the reporting burden at the service delivery level and delays in publishing national statistics were common. At the time, data collection in Morocco’s health system was mostly paper-based, and reliable data was rarely available to policymakers in a timely manner. Data was collected primarily for administrative purposes and dissemination to citizens was limited.

In a 2016 report about the evaluation of core public health functions, the Ministry of Health acknowledged that implementing an interoperable, interconnected, electronic real-time reporting system was one of the challenges faced by the country, according to the GHS Index that measures health security capabilities of different countries.

In line with the aim of improving governance in healthcare, the World Bank allocated USD 30 million towards improving HMIS in the country and added a sub-component in the project after a request from the government of Morocco.

The biggest challenges to Morocco’s health system included difficulties in EHR selection, repetition of identical errors due to fragmentation, lack of interoperability, inadequate financial and human capital, and lack of cooperation. In 2019, the GHS Index said that “there is no publicly available evidence that the government of Morocco operates a reporting surveillance system at both the national and sub-national level.” However, it acknowledged that an interoperable, interconnected, electronic real-time reporting system was under development in the country.

Morocco has been laying the groundwork for a holistic health management information system and already has a legal framework meant to protect the identifiable health information of individuals, such as that generated through health surveillance activities. Physicians, surgeons, health officers, and other healthcare workers can face fines and imprisonment if they reveal health information without any legal obligation or authorization. According to Article 43 of Law 131-13 “On Exercise of Medicine”, which was issued in February 2015, medical practitioners are required to follow rules of ethics and professional conduct which include maintaining the confidentiality of the information and the medical records of the patients.

Morocco doesn’t have an Electronic Health Record at the national level and the World Health Organization (WHO) in 2015 flagged two barriers to the implementation of EHRs as “extremely important”. These were “lack of legislation or regulations covering the use of EHR” and “competing health system priorities”.

As per the December 2019 restructuring of the World Bank project plan, the Moroccan government has made significant progress in operationalizing and scaling up national digitized health management information system on maternal and child health, family planning, and curative care (SMIPF-SC), which is going to remain the main integrated information system until the scale-up of patient-level electronic medical records. This process could take longer than what was earlier being anticipated, and in the meantime, significant resources have been spent on increasing the coverage of SMIPF-SC.

In 2020, the MoH increased its budgetary commitments on health information systems for 2020, according to a World Bank report that also claimed that a fully electronic health information system has been made operational in Morocco and laboratory test results are regularly updated in the system, enabling real-time epidemiological reporting and informing evidence-based decision-making to fight COVID-19.

The World Bank’s project in Morocco was granted Additional Financing of USD 35 million in 2020 to support Morocco’s health response to COVID-19 and one results area focussing on the emergency COVID-19 response was added to the project. In particular, this results area is meant to support the enhancement of disease detection capacities, laboratory equipment, and systems to ultimately improve the efficiency of aspects related to case detection and contact tracing.

Although a fully electronic health management information system has been put in place, some disparities remain and the World Bank has promised additional support “to strengthen health management information systems to facilitate recording and on-time virtual sharing of information.”

As mentioned earlier, one of the biggest challenges facing Morocco’s COVID-19 response is limited resources and the supply chain disruptions caused by the pandemic could worsen the situation. The World Bank has identified this as a key fiduciary risk and the MoH is supposed to quickly deploy an information system capable of centralized inventory management and assessing further needs of COVID-19 response.

Conclusion

Morocco’s response to COVID-19 has been commendable as the country managed to limit the burden on its health system in the initial months of the outbreak despite facing huge resource gaps and sharing a land border with Spain – a particularly hard-hit country during the early stages of the outbreak. The North African country imposed a state of emergency when it recorded just 77 cases and the timely action helped reduce the burden on the health system.

By mid-June, Morocco managed to reduce daily cases to an average of just 100 a day and total cases in the country hovered around 9,000. The country started easing restrictions but that resulted in a sharp surge in cases that crossed the 80,000-mark in September.

Even though Morocco still fares well in terms of cases per million population, the increase in cases has since been overburdening the health system in several cities including the main tourist hub Marrakech, where doctors protested against unsafe conditions and images of patients lying on the floor in crowded hospitals, went viral.

In a country like Morocco that is restrained with limited resources, timely availability of reliable healthcare data is critical in making informed evidence-based decisions. The country has been working with the World Bank to improve its HMIS and is said to have set up a fully electronic system that enables real-time epidemiological reporting. But discrepancies remain in the system and it is also not equipped with inventory management tools for healthcare supply chains. Such tools are critical in the context of COVID-19, especially in the case of Morocco, to ensure efficient resource allocation that can save lives.

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