Progress of Morocco’s Social Protection Generalization Plan (2021–2025). TAOUJNI SAAD. February 19th, 2025.

 

In 2002, after five decades of studies, seminars, and debates, Law 65.00 was adopted, introducing basic health coverage for all Moroccan categories, including salaried workers, non-salaried workers, and beneficiaries of medical assistance (RAMED). However, the government had yet to issue a substantial number of regulatory texts, hindering the effective and comprehensive implementation of this law, not only for salaried workers but even more so for the other two categories. In 2020, the State acknowledged that 22 million residents lacked compulsory health insurance and committed to generalizing social protection. Morocco's approach, however, only covers four branches (1. family allowances, 2. retirement benefits, 3. compulsory health insurance, and 4. unemployment compensation) of the nine branches described in Convention 102 of the International Labour Organization (ILO), which established minimum standards for social security in 1952. Other branches have been added since then.

The core provisions on compulsory health insurance in Framework Law 09-21 on social protection by 2025, enacted in 2021, are not new. They build upon pre-existing laws and regulations organizing health insurance, such as Law 65-00 (2002) on salaried workers, the 2012 Decree on medical assistance to the destitute, and Law 98-15 (2017) on self-employed and non-salaried workers. It did not include the fourth category, AMO Achamil (2023), which covers all individuals not classified under the other three categories. Strangely, this category remained optional rather than mandatory. Rather than addressing the shortcomings of the existing system, it was simply maintained without thorough analysis or necessary corrections, leading to recurring dysfunctions.

The only change was the expedited adoption of regulatory decrees establishing contribution amounts, which triggered numerous protests from self-employed workers, resulting in a membership rate of no more than 13% of the 11 million target beneficiaries by the end of 2024 and less than 2% for the 4 million eligible under AMO Achamil. This outcome underscores the near-total absence of a participatory approach. Notably, in 2021, both chambers of Parliament swiftly adopted the law without any amendments, despite the lack of a comprehensive strategic study or well-founded scenarios based on a rigorous methodology and reliable statistical data provided by an independent body.

Unlike the approach undertaken by the Development Model Committee, the proposed scenarios were not presented to the public, the parties, social partners, or experts involved in their development. The Framework Law itself is a concise document of merely 19 articles, which can be summarized in a simple table (see below) outlining the target population, funding, and deadlines: 1. family allowances (20 billion dirhams), 2. retirement (16 billion dirhams), 3. compulsory health insurance (14 billion dirhams), and 4. compensation for loss of employment (1 billion dirhams). It is important to note that Morocco’s minimal job-loss compensation cannot be compared to unemployment benefits, which represent a key pillar of social protection worldwide and are designed to guarantee a compensatory income in the event of job loss, particularly during crises like the COVID-19 pandemic:

  

Generalization of Social Protection: Population, Funding, and Planning
Benefits	Population in Millions	Legal Framework	Date	Funding in Billions
AMO	TNS + Independent : 11 M	Law 98-15	2021	5
Assistance to the Destitute	Poor + Informal: 11 M	Law 65-00	2022	9
Retirement	TNS + Independent: 5 M   Achieved: 3 to 5K	Law 99-15	2025	16
Family Allowances	7 M Children or Families	Law No. 58-23 on the Direct Social Assistance System	2023 2024	14,5
Social Aid				5,5
Job Loss Compensation	No announced target. Achieved: 15 to 20K	Law 03-14	2025	1
Total				51

It must be noted that the allocation of these projected amounts did not reflect the actual weight of each branch, as seen in comparable systems. Family allowances should not exceed expenditures on retirement, health insurance, and job-loss compensation. The total expected funding amounts to 51 billion dirhams annually, or 255 billion dirhams over five years, corresponding to the period of generalization. This figure is equivalent to the total tax revenues of the 2021 budget. The private sector is expected to contribute 28 billion dirhams annually, a stark contrast to its 4-billion-dirham contribution to the COVID Fund, while the State will provide 23 billion dirhams. Notably, the budgets approved by Parliament in the first four years of the project do not include these amounts, raising concerns about the feasibility of the proposed funding model.

In fact, this is a contributory insurance system. Compulsory Health Insurance (AMO) under the CNSS is run like a private insurance company, following the same financial principles and management rules. The similarities are striking: benefits, guarantees, tariffs, and reimbursement rates are all fixed. The only variable element is contributions, which increase annually in line with payroll growth. In the private sector employee scheme, the CNSS recorded a surplus exceeding 45 billion dirhams by the end of 2023, a figure inconsistent with the objectives set by the law establishing the AMO. This raises a critical question: How can a public health fund accumulate a surplus that any private insurance company would envy in its health branch?

Instead of being allocated to improving access to health care for insured persons by reducing the financial burden of high healthcare costs, this surplus is used in areas far removed from social issues. Despite a 2019 decision by the Board of Directors, a sovereign body chaired by the Supervisory Minister, to raise the reimbursement rate from 70% to 80%, aligning it with that for public servants insured by the CNOPS, the Ministry of Finance continues to invoke financial balance concerns to justify blocking any adjustments. The National Reference Tariff has been frozen since 2006. It is widely disregarded by many private healthcare providers, seldom controlled or denounced by the Ministry of Health, health insurance management bodies, or the two regulatory agencies: namely, the National Health Insurance Agency (ANAM) and the Insurance and Social Protection Control Authority (ACAPS). The out-of-pocket expenses for the insured amount to 60% of the actual costs incurred for outpatient care or non-chronic diseases, according to the Economic, Social, and Environmental Council, a constitutional institution. According to ANAM, the out-of-pocket share amounts to 22% for chronic diseases. In countries with genuine Universal Health Coverage (UHC), these high-cost diseases are classified as exempting diseases.

The State's share of total health expenditure was 25% in 2018. Since then, no National Health Accounts have been released to provide an accurate assessment of the State's efforts in this critical area of social rights, particularly since the initiative’s launch in 2021.

It is important to note that no regulatory texts have been currently published in the “Official Bulletin of the Kingdom of Morocco’’ to establish mandatory hygiene, safety, quality, and accreditation standards in the health sector, aimed at protecting patients and healthcare professionals. As a result, judges and stakeholders lack an official reference for addressing cases of non-compliance with official regulatory standards. On the other hand, the State does not take out any medical liability insurance for public hospitals, while requiring it from the private sector, in violation of the principle of equality enshrined in the Constitution between legal entities and natural persons. Most private doctors lack professional liability insurance with coverage proportional to the potential damages they may cause in the course of their practice, leaving their personal assets at risk in the event of judgments exceeding the insured coverage limits.

In 2025, after 70 years of independence, the health coverage rate remains between 50% and 60% of the population (Taoujni, 2024), despite claims by the Head of Government, the Minister of Health, and the Minister of Budget that coverage had reached 100%. Out of the 18 million insured, 11 million are destitute or low-income, unable to afford outpatient care in the private sector (where available) and unable to endure the reimbursement process.

During the presentation session of its opinion on 20 November 2024, the CESE, having announced a medical coverage rate of 86.5%, Mr Taoujni expressed reservations about the various constituent elements of this rate, based on data provided by other constitutional institutions (see below). Mr Chami, President of the CESE, stated that they came from the management bodies and public authorities.

However, on 21 February 2025, Mr Baitas, government spokesperson, announced that this rate was only 67.1%.

This confirmation three months later raises a fundamental question: how could such a significant gap have existed?

A gap of almost 20 points is not due to a simple statistical error, but to a methodological problem or a lack of transparency that deserves explanations. These figures are not simple technical indicators: they guide political decisions, influence citizens' perceptions and determine the credibility of commitments made in terms of social protection.

However, apart from the rate retained, the CESE report is rich with numerous findings of proven dysfunctions that have not been corrected and also offers relevant recommendations to fix them, however the press has almost only spoken about the rate of 86.5%. Hence the importance of credible statistics. 

Mr. Baitas did not provide a study as detailed and argued as that of the CESE. He also did not cite his sources. The vagueness still persists. 

This case clearly illustrates the importance of a rigorous analysis and a permanent questioning of the figures put forward in public debates. It is essential that this vigilance be generalized to guarantee the integrity and effectiveness of public policies.

An analysis of the State budget and public institutions shows that public investment expenditure continues to rise, reaching 24% of GDP, amounting to 340 billion dirhams.

The Social Protection Support Fund, a special treasury account, has never exceeded 10 billion dirhams in annual expenditure from 2020 to 2023, maintaining the same level as before the COVID-19 pandemic. This fund supports 100 social programs, benefiting several million people in a country where nearly 50% of the population lives in poverty or precarious conditions, a situation further exacerbated by climate change, economic instability, and the COVID-19 crisis, along with their impact on unemployment. In 2023, 9.5 billion dirhams was allocated to AMO TADAMON (formerly RAMED), while 0.5 billion dirhams was designated for 2.4 million people with disabilities.

Infrastructure investments take precedence over social spending in Morocco, with the ninth Sustainable Development Goal (SDG) being the country's top priority. However, State-led projects often yield low employment returns, as reflected in the ICOR index, which measures the profitability of public investments. In Morocco, the ICOR index stands at 9.4 over nearly 20 years, compared to an average of 5.7 in lower middle-income countries during the same period.

Where is the "social state" that public authorities so frequently claim to uphold? 

In welfare states, health and social protection budgets align with the constitution, typically representing 50% to 60% of total public spending (compared to only 7% in Morocco in 2023). For instance, in Spain, this budget is ten times higher than that allocated to equipment, highlighting the disparity in budgetary priorities.

Before drawing conclusions, observers must critically assess all data provided by the government, which is later disseminated by the media, certain influencers, and occasionally even academics or foreign experts, many of whom fail to verify the accuracy of demographic, financial, or medical information.

The issue of medication pricing is a significant concern. Medications account for more than a third of total health expenditure, yet some are priced higher in Morocco than in more developed countries, a discrepancy that is often difficult to justify. The regulatory, pricing and importation policy of chronic disease drugs, as well as methods of distribution, safety stock management and prescription require careful consideration. Pricing should be reassessed through a detailed benchmark analysis. Comparing prices with countries of similar income levels and adopting best international practices would offer valuable insights. In many of these countries, some high-priced medications cost two to three times less than in Morocco.  While it is true that such medications are often provided free of charge in these countries’ public hospitals, Moroccan policymakers have taken a markedly different approach, favoring the expansion of an unregulated private sector, to the detriment of a public healthcare system already facing a severe shortage of human resources.

The comprehensive pension reform has been on hold since 1990, despite repeated recommendations from World Bank reports (2005) and the ILO (2012) for its implementation. In 2016, a parametric reform was introduced, but it applied solely to the Moroccan Civil Servants Pension Fund (CMR). Meanwhile, the average CNSS pension for private sector employees remains below 2,000 dirhams. Pension rights are better safeguarded in the public sector, whereas in the private sector, the average declared salary is half that of public employees. With just ten months left before the completion of the five-year generalization plan, the government has yet to introduce a single bill or disclose its chosen reform scenarios.

In 2022, the country also declined in two key indices: the Gini Index, which measures social inequalities, dropped by seven points, according to the High Commission for Planning, while the Gender Equality Index placed Morocco among the ten lowest-ranked countries.

Therefore, the excessive use of the social state concept is undoubtedly aimed at local political and media purposes. The government has prepared the population for the dismantling of the Compensation Fund and the liberalization of subsidized gas and food prices. In the short term, the State's savings from this dismantling will surpass the costs of direct social assistance. The poorest populations have begun receiving modest financial aid, yet the middle class will continue to bear the burden of price fluctuations and rising social and tax levies. Meanwhile, most regions of the country still lack access to healthcare and education services that meet basic quality and safety standards.

Ensuring fair pricing in essential goods is not just an economic necessity but also a social imperative. Civil society must push for greater transparency and genuine competition to drive down costs, whether for medicines, hydrocarbons, or other key products. Lowering these prices would directly ease household financial strain and improve overall well-being while also alleviating pressure on health insurance organizations.

https://panorapost.ma/post.php?id=44008 "Half of Moroccans without AMO". Saâd Taoujni. January 17, 2024.

This article was updated on February 27, 2025.