How did Morocco implement?

Health system structure

Morocco’s health system is organized into two sectors: (1) the public sector, represented by the services of the Ministry of Health and Social Protection (Le Ministère de la Santé et de la Protection Sociale, MSPS) and those of the Royal Armed Forces, and (2) the private sector, with both for-profit and nonprofit private institutions. The Ministry of Health and Social Protection was known as the Ministry of Health (Ministère de la Santé) prior to 2021. Since 1990, Morocco’s health system has shifted to a regionally directed model. Access to delivery care services is based on a hierarchy of public and private providers, which are illustrated as a pyramid in Figure 15. The layers of this pyramid represent the networks of public sector health facilities, from primary care at the community level up to referral hospitals, supported by emergency transport, support structures, and other sociomedical facilities.

The first level of care is the primary health care facility network, or réseau des établissements de soins de santé primaires (RESSP).^1,2 RESSP is the first line of access to health services for the public, and services are free for the entire population at this level. There are two levels of primary health care facilities: the first level provides care in the community and offers basic health care services, and the second level covers a larger population and provides more advanced services including basic emergency obstetric and newborn care (BEmONC).¹

Specialized care is available through various levels of the hospital network, or réseau des établissements hospitaliers (REH).^1,2 Patients are referred to the REH from RESSP, with increasing referral levels from local hospitals up to provincial, regional, and interregional hospitals. Local hospitals have up to 60 beds and provide medicine, surgery, obstetrics, pediatrics, and emergency care.

The integrated emergency medical care network, or réseau intégré des soins d’urgence médicale (RISUM), helps transport patients from home to facility or between facilities.^1,2 Coordination for the emergency care network and ambulances is done by the Service d’Assistance Médicale Urgente (SAMU), the regulatory center, and the Centre de Régulation des Appels Médicaux, the medical call center.³ Emergency transport is provided by various types of ambulances (public system, private, and municipal ambulances), known as Services Médicaux d’Urgence et de Réanimation (SMUR), and Matériels de Transport et de Secours de Base (MTSB).

The network of sociomedical institutions, or réseau des établissements médicaux sociaux (REMS), are integrated at every level of public health care in Morocco.^1,2 Common sociomedical institutions include physical rehabilitation centers, addiction centers, university medical centers, palliative care centers, youth health centers, and more. In addition, mobile health teams carry out community outreach activities, covering populations that live farther than 6 km from a health facility or face specific geographic obstacles.^1,2

Morocco’s public sector plays a key role in maternal health, with 81.6% of institutional deliveries occurring in public facilities as of Morocco’s 2018 Enquête Nationale sur la Population et la Santé Familial (ENPSF).⁴ Private facilities are gradually rising in popularity for maternal, newborn, and child health (MNCH) services but remain the minority. Shown in Figure 15, private sector facilities exist outside of the public facility network and have similar types of primary care and hospital facilities. Common nonprofit private facilities are operated by the National Social Security Fund (Caisse Nationale de Sécurité Sociale, CNSS), Red Crescent Society, and other groups. Common for-profit private facilities are hospitals, offices, pharmacies, imaging services, and dental services.

Health facilities

According to the Ministry of Health and Social Protection (Ministère de la Santé et de la Protection Sociale, MSPS) Santé en Chiffres reports that the density of public sector primary health care facilities, or the RESSP, has remained relatively constant since 2000 at about 7 to 8.5 facilities per 100,000 population, suggesting that availability has matched the pace of population growth.^5,6 This density represents an average of about 12,000 to 13,000 inhabitants per RESSP facility. This data also found that about 71% of RESSP facilities were in rural areas in 2022.⁵ As a national-level policymaker shared, more women have been able to access maternity care services via this continued expansion of RESSP:

In addition to the public sector, many private sector primary care clinics exist, and are well-established especially in urban areas.

Hospitals play an integral role in Morocco’s health care system, especially in MNCH services. In 2018, 56.5% of all deliveries occurred in public hospitals and 14.6% of deliveries occurred in private hospitals. Though many low- and middle-income countries tend to rely more on the network of lower-level facilities for institutional delivery, Morocco has successfully enabled the provision of obstetric care at the hospital level for much of the population – though access by women in remote areas can still be challenging.⁷ Compared to lower-level facilities, increased hospital delivery can improve timely access to emergency obstetric maternal and neonatal care provided by skilled health professionals in an enabling environment.⁷

Human resources for health

Morocco’s health system relies primarily on doctors, nurses, and midwives for health system delivery. According to World Health Organization (WHO) health workforce data, Morocco’s density of doctors grew from 5.3 to 7.3 per 10,000 population from 2004 to 2017. The density of nurses/midwives grew from 8.1 to 13.9 per 10,000 population over this same period, representing a large increase of about 25,000 nurses and midwives (Figure 16).⁸ Several contributors to these increases included reforms in higher education, as well as key policies introduced in 2008 and 2012 which included components to improve health workforce training.

In 2016, WHO proposed an updated threshold density of 44.5 physicians, nurses, and midwives per 10,000 population to achieve the Sustainable Development Goals and work toward universal health coverage.⁹ Morocco’s health workforce density of these cadres was 21.23 per 10,000 population in 2017, suggesting additional health workforce development would be beneficial to meet the target. More recent data from the MSPS published in 2022 noted a density of 7.62 doctors per 10,000 population, evidence that the health workforce is continuing to grow.⁵

Of the doctors, nurses, and midwives in the public sector, the hospital network employs 67% of health care professionals.⁵ RESSP facilities employ 32% of the public sector health workforce, while REMS facilities employ the remaining 1%.⁵ Hospitals typically have more specialist doctors and nurses supporting patients, while RESSP facilities are primarily staffed by general doctors, nurses, and midwives.⁵

Skilled birth attendance by a medical professional has risen substantially from 31% of births in 1992 to 86.6% in 2018.⁴ In 2018, antenatal care (ANC) and postnatal care (PNC) services were provided primarily by doctors. In 2018, 72.2% of women saw a doctor during their ANC visits and 63% of women who received PNC from a skilled provider received it from a doctor.⁴

While the majority of maternal and delivery care occurs in the public sector, the private sector still employs a large percentage of the country’s overall health workforce. Both the public and private sectors had approximately the same number of doctors in 2022, each having around 14,000 doctors and a comparable mix of specialists and generalists.⁵ Specialists constitute about 62% of the physician workforce in the private sector and 74% of the physician workforce in the public sector, though these figures are not mutually exclusive as specialists may practice across both sectors.⁵

Morocco’s efforts to improve the skills and availability of the health care workforce through various policies are described in the Skills Development of Health Care Professionals subsection below.

Mortality reduction plans

Moroccan policymakers started to explicitly address the challenge of high maternal mortality as an issue related to women’s rights during the 1990s and 2000s. Two of Morocco’s key policies to influence maternal and neonatal mortality were the 2008–2012 Maternal Mortality Reduction Acceleration Plan (Plan national pour l’accélération de la réduction de la mortalité maternelle et néonatale), and the 2012–2016 Maternal and Neonatal Mortality Reduction Acceleration and Consolidation Plan (Plan de consolidation de réduction de la mortalité maternelle et néonatale). Throughout this narrative, these policies will be referred to as the 2008 Acceleration Plan and the 2012 Consolidation Plan. The following sections will share more in-depth information about the components of these plans and how they were implemented.

Morocco’s political climate at the time created an environment favorable to MNCH policies, including support from the prime minister and advocacy for change from society at large.¹⁰ Morocco’s first-ever female minister of health, Yasmina Baddou, also placed a high political priority on the reduction of maternal mortality during her 2008–2012 tenure. Early in her term, a national commission was established to design the 2008 Acceleration Plan to meet the global Millennium Development Goals and to reduce the maternal mortality ratio (MMR) in Morocco to 50 maternal deaths per 100,000 live births.

The components of the 2008 Acceleration Plan were structured under three pillars (Figure 17):^11,12

• Reduce barriers to access and improve the availability of qualified personnel
• Improve the quality of care during pregnancy and delivery
• Improve governance and management

A marquee action of the 2008 Acceleration Plan was the elimination of user fees from emergency obstetric and newborn care. Morocco also developed programs to improve the skill level of health care professionals, upgrade public maternity care facilities, and streamline access to health care in rural areas via free emergency transportation.

Strong political will to mobilize financial support was crucial to the implementation of key MNCH policies in Morocco. Together, the Ministry of Health and the Ministry of Finance mobilized a budget of approximately 1.3 billion Moroccan dirhams (approximately US$175 million) over five years to implement this plan.^10,11,13 Spending on the 2008 Acceleration Plan was approximately 2.8% of the overall budget of the Ministry of Health.¹⁰ A public health expert shared:

According to an impact evaluation of the policy, approximately 57% of the projected five-year budget was spent on free emergency obstetric and neonatal care.¹⁰

The 2012 Maternal and Neonatal Mortality Reduction Acceleration and Consolidation Plan was enacted to solidify the gains from the previous years, and to reaffirm the political commitment to achieving the MNCH components in the Millennium Development Goals.^14,15 The 2012 Consolidation Plan built upon and consolidated the strategies from the 2008 Acceleration Plan, with the following key actions for maternal and neonatal health.

Maternal health:

• Consolidation of the fee exemption policy for emergency obstetric and neonatal care
• Improvement of quality of care for obstetrical complications
• Strengthening of local responsibility for monitoring pregnancy and childbirth
• Improvement of regional program management

Neonatal health:

• Upgrading of childbirth facilities
• Organization and strengthening of neonatology care services
• Strengthening of neonatal monitoring during the postpartum period
• Improvement of the quality of care for the newborn
• Implementation of an information system and research in perinatal health

The 2012 Consolidation Plan also introduced a regional action plan in 2013, the Saving Lives of Mothers and Children Initiative, which was developed following the Dubai Declaration.¹⁶ This action plan targeted six subnational areas accounting for over 60% of the population, with lower coverage of MNCH indicators and higher maternal and neonatal mortality rates. The national government delegated funds to regional task forces, which developed and drove specific implementation plans for their area.

These policies will be discussed throughout this section, as they influenced many levers that drove progress in MNCH outcomes in Morocco.

Removal of user fees

Removing user fees for delivery care was a core component of the first pillar in the 2008 Acceleration Plan, shown in Figure 17. This landmark policy removed user fees for obstetric care in public facilities, including delivery and C-section costs, for women regardless of their socioeconomic status or geography.¹¹ The 2008 Acceleration Plan also removed user fees from emergency referral transport from a lower-level to a higher-level facility for all women. Additionally, user fees were removed for emergency transport from home to facility for women in rural areas.

The subsequent 2012 Consolidation Plan broadened the removal of user fees from more services, including for treatment of complications during pregnancy, including ectopic pregnancy, abortion, premature delivery, eclampsia, hemorrhage, and infections.¹⁴ User fees were also removed from postnatal care, various diagnostics during antenatal care, referral costs, and newborn care.¹⁴

Overall, these policies helped minimize financial barriers to maternal and neonatal health services in Morocco. As explained by a public health expert:

As part of both policies, the government introduced reimbursements to public facilities for provision of obstetric care.¹¹ Reimbursements were calculated based on the expected volume of deliveries and types of services provided.¹⁰

An assessment of these free obstetric care policies was conducted with 973 women across six provinces in 2015.¹³ This analysis found that 72% of women did not have to pay hospital fees during their stay, and that the 2008 Acceleration Plan likely increased the use of hospital maternity wards, suggesting strong implementation of these policies.¹⁰ The assessment estimates that this policy reduced the costs of delivery by more than 90% for households.¹³ Within this analysis, women who delivered via C-section were more likely to have to pay: 10% of women with normal deliveries incurred costs compared to 27% of women delivering via a C-section.¹³

Skills development of health care professionals

Improving the availability of qualified personnel was a core component of the first pillars in the 2008 Acceleration Plan, shown in Figure 17. Two components in this pillar were directly targeted to human resources for health: increasing training of doctors and midwives, and in-service training for existing providers.¹¹ The 2012 Consolidation Plan continued to build on these foundations: emphasizing quality of care for obstetric complications, training providers in neonatal care, and strengthening human resources for health in high-need regions. Successful implementation of human resources planning involved a variety of actors across sectors, including national and regional governments, health professional associations, and educational institutions.¹⁷

Morocco expanded and strengthened preservice education programs to increase the skill level and capacity of the workforce. In 1993, eight nurse/midwife training centers, each called an Institut de Formation aux Carrières de Santé, were developed in different regions of Morocco. These institutes launched new nurse/midwife undergraduate-level training programs and increased their duration to at least three years. Subsequently, curricula for skilled health professional programs were revised several times in the early 2000s to improve the quality of pre-service education. Revisions were led by the government, focused on skills-based training and matching curriculum to global competency standards. More broadly, the training system for midwifery, nursing, and health technician personnel underwent a comprehensive government-led reform starting in 2013.¹⁷ To strengthen another key practice area, newborn health also received increasing attention in the 2012 Consolidation Plan, with multiple pre-service and continuing education diploma programs established in neonatology for training nurses, general practitioners, and pediatricians. Examples of other new pre-service education programs introduced during this period include nurse specialization in emergency intensive care and a masters in community health.¹⁷

Specific actions in the 2008 Acceleration Plan also helped to increase the quantity of graduates from pre-service education programs. Examples include the assignment of 689 additional midwives to 167 health center maternity units, and the growth in midwifery students from 168 in 2007 to 530 in 2010.^10,11 Between 2007 and 2009, Morocco also increased the number of residency posts for obstetrician-gynecologists from 50 to 80 posts, for anesthetists from 41 to 54 posts, and for pediatricians 35 to 74 posts.^10,11 Residency posts help increase the number of physicians in hospitals, with the number of gynecologists in the public sector growing from 327 to 515 between 2003 and 2020.

To improve in-service training for existing providers, the government introduced several new education initiatives from staff involved in childbirth care. One initiative was designed to teach midwives and general practitioners from primary care settings about managing obstetric complications in a hospital setting, delivered through an annual one-week course.¹¹ This course emphasized collaborative decision making to address complications with minimal access to specialists. Mandatory refresher courses were also developed to disseminate updates to national clinical guidelines about management of hemorrhage and eclampsia. Additional programs set up obstetrician-led coaching in health center maternity units to help upskill nurses/midwives in these facilities. Approximately 2% of the five-year projected budget of the 2008 Acceleration Plan was spent on skills reinforcement, additional residency spots, and availability of midwives.¹⁰

Though doctors provide the majority of care in Morocco, various plans have helped to strengthen the roles of nurses/midwives in the health care system. In 2006, the government announced that midwives may be eligible for reimbursement if a medical doctor is unavailable.¹⁸ The landmark 2008 Acceleration Plan included a dedicated action plan to strengthen midwifery. This action plan proposed improvements to midwifery pre-service and in-service education, changes in legislation to better define midwives’ role in care provision, and reorganization of human resources management.¹⁹

Expanded physical access to care

Ambulances and emergency transport

To facilitate reductions in maternal mortality, the 2008 Acceleration Plan set out to strengthen emergency transport networks. The introduction of obstetric ambulances in rural settings was a component in the first pillar of the 2008 Acceleration Plan (Figure 17), and represented approximately 1% of the plan’s five-year budget.¹⁰ Obstetric ambulances in rural settings were introduced via the Service d’aide Médicale Urgente – Obstétricale Rurale (SAMU-OR) program, and made home-to-facility transport free of charge. The policy also removed user fees for emergency transfers between health facilities for all women in urban and rural settings.¹³

The SAMU-OR program took a community-based approach, relying on volunteer community liaison officers to help identify women with high-risk pregnancies and support their access to care.¹¹ These officers referred women to the appropriate delivery facility in the SAMU-OR ambulance based on their needs. More broadly, officers also helped raise awareness among women and their families in rural areas about the risks associated with pregnancy.

An evaluation of the SAMU-OR program in two Moroccan regions was conducted in 2013.²⁰ This evaluation found that the initiative resulted in higher ambulance availability on site and strengthened relationships between local health authorities, health care providers, and community workers. Local leadership also contributed to raising awareness of women’s and children’s rights among their citizens, including increasing rural citizens’ knowledge of fee removal for maternal health services introduced in prior health policies. Overall, the evaluation suggested that SAMU-OR resulted in better access to facilities for delivery services and improved care.²⁰

The government also strengthened emergency transport more broadly across the country to support faster home-to-facility transport as well as inter-facility referrals. As mentioned in earlier sections , user fees were removed from emergency referral transport. The 2008 Acceleration Plan also codified and standardized referral processes between facilities.¹¹ Guidance was developed and shared broadly about levels of care provided at appropriate facility levels as well as procedures to transfer.¹¹

As part of the 2012 Consolidation Plan, the government allocated a substantial budget for a national plan for emergency medical support.¹⁷ The plan had five components: improving prehospital emergency transport, restructuring emergency department facilities in health centers/hospitals, improving emergency medicine training, collaborating with public and private organizations, and adjusting regulatory and legal frameworks to support change.¹⁷

The medical emergency call line “141” was designated with the appropriate network to direct and dispatch mobile emergency services. From 2012 to 2016, 393 SMUR ambulances were purchased, serving approximately 530,000 beneficiaries.¹⁷ The transport network continues to grow, with 2022 data from the MSPS Santé en Chiffres report noting 110 SMUR and 1,256 MTSB ambulances across the country.⁵ Each region typically has between 40 and 200 public sector ambulances.⁵ As of 2022, all but three regions had at least one SAMU that coordinates emergency services.⁵

In addition to emergency transport, the RISUM emergency system consists of local urgent medical units (urgences médicales de proximité, UMP) as a first point of service in a health facility. The 2012 Consolidation Plan added UMPs in 58 community-level health centers to serve regions that face barriers in access to health care.¹⁷ As of 2022, Morocco had 92 UMP facilities.⁵ Annually, emergency room facilities in both health centers and hospitals supported 5.2 million people across Morocco in 2016.¹⁷

Rural area mobile medical units

Another component within the first pillar of the 2008 Acceleration Plan (Figure 17) was the identification of high-risk pregnancies through mobile medical units. Mobile medical teams were launched in hard-to-reach rural or remote areas to improve health service coverage in these regions.¹² They are extensions of primary health care facilities (RESSP), offering a package of integrated services to populations located 6 km or farther from the nearest facility.²¹

These mobile units traveled in a large vehicle, equipped with tools and medicine to provide an array of curative and preventive services. The units were staffed by teams of health care professionals who traveled to rural areas for one visit every few months at local accessible gathering points. In 2014, these units made approximately 12,000 visits to rural areas.²¹ Several reproductive, maternal, newborn, and child health services were provided by these teams including family planning services, antenatal care, and screening for diseases such as anemia, hypertension, and diabetes in pregnant women.¹² In 2022, data from the MSPS noted that public sector mobile medical teams delivered family planning services to approximately 57,000 women and provided at least one ANC visit to nearly 23,000 women.⁵

More broadly, Morocco has also deployed specialized medical caravans across other disease areas for specific diagnostics, operations, and surgical care: in 2014, 287 specialized medical caravans delivered approximately 266,000 consultations.²¹ In general, this type of mobile delivery mechanism continues to be a strong service delivery option for services within and outside of maternal and child health, and are also frequently deployed to respond to crises and environmental shifts.^22,23,24

Maternity waiting homes

Morocco launched a maternity waiting home program in 2006, called Dar Al Oumouma (DAO). DAO was funded within the first phase of a broader multisectoral social investment program, the National Initiative for Human Development.²⁵ By 2019, Morocco had about 100 DAOs spread across 34 provinces, serving 98,000 patients over 13 years of the program.²⁶ DAOs were present in about 5% of rural primary care facilities in 2019.²⁷

The DAO program is one community mechanism to increase women’s access to health facilities and skilled delivery care in rural areas, similar to maternity waiting home models in other low- and middle-income countries.²⁸ DAOs allow women to be accommodated in a reception facility close to the health center for two to seven days before delivery and two days after their delivery.²⁹ At the time of delivery, DAO facilitators take women to the nearby health center. In the event of complications, they are evacuated by ambulance to the nearest hospital.³⁰ After birth, DAOs also provide health education for mothers about contraception, nutrition, vaccination, newborn care practices, and young child development.^30,31

The facilities are community driven, led by a partnership of local health organizations, government bodies, and NGOs.²⁹ Midwives and health personnel from the health facility located next to the DAO typically provide services to women at the DAO.³² Data from four DAO sites in the time period 2006 to 2009 also provide insight into the program’s function.³⁰ Approximately 1,997 total women were served by the four DAO facilities in 2009, and the majority of women delivering at the health centers used the DAO. In some facilities, the DAO was found to be a comfortable place of reception for women.³¹ However, large-scale evidence linking DAO utilization to improved MNCH outcomes is limited in Morocco and it is difficult to demonstrate that, as intended, remote communities are accessing these services.

With the launch of new DAOs, UNICEF and the National Human Development Initiative have focused on improving communication efforts to inform women in remote areas about DAO services, and ensuring transportation to health facilities is available.³¹ The new DAOs focus additionally on promotion of PNC, early childhood development, and nutrition services at the community level. Moving forward, further evidence generation may be helpful to better understand the role of DAOs in improving access to health care.

Expansion of health insurance

Since 2002, Morocco has developed a variety of laws, policies, and programs that reduce financial barriers to MNCH care and health care more broadly for their population. In addition to removal of user fees discussed previously, Morocco has developed and expanded its public health insurance programs. From 2005 to 2022, the proportion of Moroccans with medical coverage rose from 15% to 78%.³³

The adoption of the Basic Health Coverage Bill in 2002 launched a set of health financing reforms to establish universal health coverage via social health insurance systems.³⁴ In 2005, basic compulsory health insurance was introduced for salaried workers, known as Assurance Médicale Obligatoire (AMO).³⁵ AMO was a mandatory and contributory health insurance program for employees in formal private and public sectors. The National Social Security Fund (Caisse Nationale de Sécurité Sociale, CNSS) managed AMO for private sector employees, while the National Fund for Social Welfare Bodies (Caisse Nationale des Organismes de Prévoyance Sociale) managed the scheme for public sector employees.^34,36 AMO was expanded more broadly to students and the self-employed in 2016.³⁵ AMO provided full and comprehensive health coverage in public facilities (90% reimbursement) and private facilities (70% reimbursement), including childbirth, medical/surgical hospitalization, medical devices, and medications.³³ In 2019, approximately 10.1 million beneficiaries, or 30% of the population, was covered by AMO.³⁷

The Régime d’Assistance Médicale aux Economiquement Démunis (RAMED) was piloted from 2008 to 2010 in one region and was recommended for national coverage within one year.³⁶ RAMED was scaled up to all low-income individuals across Morocco in 2012.³⁸ RAMED is a non-contributory basic coverage scheme that provides a wide range of health benefits for citizens of low socioeconomic status and other marginalized groups.³⁶ RAMED is managed by the National Health Insurance Agency. Benefits covered by RAMED include basic free health care services in public hospitals and health centers, including emergencies and hospitalizations.³⁶ For MNCH care specifically, it provides exemption from payment for low-income individuals at public health facilities, and includes coverage for C-section and obstetric complications.^38,39 In 2022, RAMED had 11 million beneficiaries, around 30% of the population, and higher coverage in rural and poorer regions.^33,39,40

Since the research period was completed, new programs have been launched in Morocco. In 2020, the Ministry of Health (Ministère de la Santé) announced that RAMED and AMO would become integrated as a program of social coverage for all Moroccans.⁴¹ The programs merged into a program called AMO-Tadamon by 2022, run by the CNSS (Figure 18). Under this program, all beneficiaries would receive health care from both public and private clinics, which improves access to health care and reduces the burden on public facilities.⁴² Contributions to this new program are based on income levels. Former RAMED beneficiaries do not have to contribute the same amount as AMO beneficiaries.³³ AMO-TNS is another insurance program announced in 2022 for non-salaried workers, such as farmers, traders, and artisans.⁴³ As of 2024, 22 million people will be eligible for AMO-Tadamon and AMO-TNS.⁴⁴

The sources of health expenditure in Morocco from 2000 to 2020 are shown in Figure 19. Following the launch of AMO in 2005, data from 2006 indicate that social health insurance accounted for about 16% of health expenditure. Through the RAMED launch and the growth of AMO and RAMED, out-of-pocket spending decreased from about 60% of health expenditure in 2005 to 42% in 2020. Estimates of catastrophic health expenditure also reflect the success of health insurance implementation and financial protection. There was a decrease in the proportion of Morocco’s population spending greater than 10% of total household expenditure on health care expenses, from 22% in 2006 to 8.2% in 2019.⁴⁵ Decreases in out-of-pocket spending and catastrophic health expenditure proportions suggest that Morocco’s health insurance programs are helping to protect citizens from substantial health care costs. Ultimately, improvements in coverage and financial protection contribute to better access to health care for Moroccan citizens.

Service quality and facility readiness

Morocco took specific actions to improve quality of care in health facilities, enabling more facilities to provide high-quality care to mothers and newborns. Improving quality of care during pregnancy and delivery was the second of three pillars in the 2008 Acceleration Plan (Figure 17). There were two components within this pillar: (1) audit and upgrade of maternity care facilities; and (2) improved quality of patient experience in facilities through improved communication, respect, and privacy. The 2012 Consolidation Plan continued to build on these components to strengthen access to urgent obstetric medical care, especially in the six targeted high-need regions. As one national level policymaker shared, substantial efforts have been dedicated toward facility upgrades, enabled by an increased budget:

This section will explore various programs that helped to improve quality of care and facility readiness:

• Audit and upgrade of public maternity care facilities
• Improvements to medicine/equipment availability
• Introduction of certification processes
• Introduction of a competition for maternity hospital quality
• Enhanced quality of ANC and PNC
• Development of maternal death surveillance system and reporting tools

Audit and upgrade of public maternity care facilities

As part of the audit and upgrade of maternity care facilities, Morocco conducted an audit of maternity care facilities (90 maternity hospitals and 518 health centers with maternity units) in 2008.¹¹ This audit showed that only 28% of facilities provided basic emergency obstetric and newborn care (BEmONC) services and 69% of maternity hospitals provided comprehensive emergency obstetric and newborn care (CEmONC) services. The analysis spurred a large investment to upgrade the physical infrastructure within public maternity hospitals, representing around 18% of the policy’s budget.¹⁰ In 2008, 16 maternity hospitals were renovated, with the renovation program expanding to other hospitals and health center maternity units in 2011. Some renovations improved the privacy of delivery rooms, added reception/waiting areas for family members, and provided new medical technology.

Beyond physical infrastructure improvements, the 2008 Acceleration Plan advocated patient experience as a priority in the health system. Patient safety indicators were integrated into the criteria for hospital accreditation and quality improvement processes. Morocco also established a national platform for adverse event reporting in hospitals, and created a patient hotline accessible via a toll-free number to report corruption or lack of respect in the medical system. In some facilities, particularly in private ones, a family member was allowed to attend delivery upon the patient’s request.

Improvements to medicine/equipment availability

Morocco made concerted efforts to improve medicine and equipment availability, beginning with a commission-led analysis of the Ministry of Health’s essential medicines list compared to WHO’s essential medicines list. Examples of MNCH commodities added to the list include misoprostol and magnesium sulfate. To increase facility readiness for obstetric services, the government developed a program to provide essential drugs and birth delivery kits based on expected delivery volumes. Blood transfusions were included in the 2008 free delivery care package, thus ensuring blood availability in facilities was also part of this program.¹³ An impact evaluation of the 2008 Acceleration Plan found that the number of birth kits supplied more than doubled at all health facility study sites.¹⁰ Throughout the 2012 Consolidation Plan, the government increased public spending on medications, and improved the supply chain to ultimately lower the prices of essential medications and medical tools.¹⁷

Introduction of certification processes

Morocco also introduced a certification process for birthing centers in late 2008, with a goal to bring facilities up to the required standard of care and to ensure compliance with EmONC recommendations.⁴⁶ The certification process used a combination of facility-based self-assessment and external evaluations, assessment of access to care, EmONC service availability, quality of care, and organizational components. This certification process was regionalized in 2013 as part of the 2012 Consolidation Plan, with a more participatory approach led by regional committees. A 2015 policy made certification a mandatory procedure for facilities with birthing centers.⁴⁷

Introduction of a competition for maternity health facility quality

Another quality improvement initiative launched in 2005 was the annual competition for maternity health facility quality, organized every 18 months.⁴⁸ The government made participation in the competition mandatory as part of a broader quality improvement project, and dedicated around 1% of the plan’s budget to the initiative.^10,46 The competition evaluated the quality of health facilities on dimensions including satisfaction, accessibility, availability and continuity, rationalization of resources, safety and responsiveness, leadership and continuous improvement, partnership and participation.⁴⁶ Steps in the competition process included a self-assessment, an external audit, and then a ranking and performance disclosure based on the scores.⁴⁸ Awards were given to the top ten facilities, incentivizing local officials and managers to improve.⁴⁶ Evidence suggests that these competitions helped to improve performance for participating facilities.^48,49

Enhanced quality of antenatal and postnatal care

Enhanced quality and equipment extended to other key maternal health services, such as ANC and PNC. One notable change in the 2008 Acceleration Plan was the initiation of a mandatory 48-hour stay for women and neonates in all facilities to ensure appropriate provision of postnatal care. The 2008 Acceleration Plan earmarked about 20% of its budget for reinforcements to the provision of ANC, family planning, and mobile care delivery.¹⁰ Several legal decrees during the 2008 Acceleration Plan and 2012 Consolidation Plan supported this change and other quality improvements in childbirth care^15,50:

• Recommendation of at least two ultrasounds, a clinical examination, and biological tests (hemoglobin, blood group, syphilis screening, urine test) during ANC visits
• Introduction of free standard biological ANC checkup in hospital setting
• Introduction of mini-analyzers for biological and hematological examinations
• Reinforcement of the coverage and quality of prenatal and postnatal consultations, recommending at least four ANC visits (first trimester, second trimester, eighth month, ninth month), three PNC visits, referral to specialist doctors for high-risk pregnancies, continuing education for health professionals, and reinforcing medicine availability for consultations
• Postpartum care for the mother–newborn dyad in the first 48 hours after delivery

Development of maternal death surveillance system and reporting tools

Launching the Maternal Death Surveillance System (SSDM) was a component within the third pillar—improving governance and accountability—of the 2008 Acceleration Plan. The institutionalization of the SSDM contributed to improving service quality for maternal and neonatal care. Morocco introduced a law in 2009 that obligated the notification of deaths of women ages 15 to 49 years as well as confidential audits into the cause of death. It also allocated a dedicated portion (~0.3%) of the five-year plan budget to the initiative.¹⁰ From 2009 to 2020, three national reports were published about the numbers and causes of maternal death, in 2010, 2011, and 2015, in addition to five other regional reports. Estimates in the 2010 report suggest that approximately 45% of deaths among women of reproductive age were accounted for in the surveillance system.⁵¹ The 2012 Consolidation Plan had several actions to strengthen the SSDM, including calling on local communities to report deaths through civil registration offices and municipal/communal hygiene offices, decentralizing the audits to regional committees, and launching a National Unit for Maternal Mortality Surveillance.⁴⁷ In 2017, the SSDM was operational in 10 of the 12 regions in Morocco.⁵² In seven regions, all SSDM components were implemented, and four regions were able to integrate activities into routine practice to use the data to improve maternal health programs.⁵² Morocco’s 2017–2021 Every Newborn Action Plan and Ending Preventable Maternal Mortality (ENAP/EPMM) strategy established a neonatal death surveillance system to continue to understand causes of death to improve service quality.⁴⁷

Through these and other programs, Morocco has made strides in improving service quality and facility readiness for MNCH services in the past two decades.