Social inequalities and health inequity in Morocco

As indicated by the 2002 Arab Human Development Report [2], the per capita income in Morocco is growing very slowly indicating a quasi-stagnation of economic growth and a relative deterioration in the average standard of living for the whole population. This global problem of low income is exacerbated by bad governance and huge inequalities. Indeed, the ratio (11.7) of the richest 10% to the poorest 10% is excessively high compared with developed countries and even with developing countries (Table 1). As a corollary, 19% of the Moroccan population live under the national poverty line, of which 70% are living in rural area, yielding a second discrimination at a regional level. The estimated earned income of women is less than 40% of that of men and the share of non-agricultural wage employment is 73% for men and 27% for women. Consequently, the discrimination encountered by a poor rural woman is threefold. The inequality is found even in the same administration sector. For instance, the salary of a primary teacher represents just 4% of the salary of a president of a university.

After 50 years of independence, 50% of the Moroccan population aged 15 and above are illiterate with women representing nearly 2/3. As showed in Table 2, very few Arab countries do worse than Morocco. Knowing that illiteracy rates in the Arab world remain higher than the international average and are even higher than the average in developing countries, it is clear that the burden of illiteracy will continue to affect the human development index of Morocco for a while.

A similar statement can be made for the combined gross enrolment rate in primary, secondary and tertiary schools (Table 2 columns 3&4). Once more, Morocco is seven points below the average of the Arab countries (57 vs. 64). As stressed by the 2002 Arab Human Development Report [2], Morocco and the Arab countries are not expected to catch up with the industrialized countries' mid-1990s enrolment levels for all three levels of education before 2030!

Moreover, for literacy and enrolment, the gap between Moroccan rates and the Arab world average is much accentuated for women (24.5 and 10.8 respectively) than for men (15.7 and 4 respectively).

In general, as indicated in Table 3 for literacy, Moroccan inequality is at least a three-dimensional space, spanned by Milieu, Sex and Income class.

In Morocco, until recently, health was considered as a non-productive sector. Indeed, during the last four decades, the budget affected to health represented, on average, 1% of GDP each year and bad governance conducted to an ill-health system. Consequently, by the dawn of the third millennium, only 40% of births are attended by skilled health personnel, many women continue to die during childbirth and infant mortality rate remains relatively high Table 4). With an average of one doctor for 2100 inhabitants, Morocco compares badly with countries of equivalent level of development. Moreover, the partition is unfair since the numbers vary from one doctor for 840 inhabitants in one region to one doctor for 4600 in another region (Table 5). Inequities are also found between cities and rural areas, with nearly 30% of the rural population living at a distance of 10 km from any health facility. More generally, the global health expenditure is very low and mainly supported by households (60%), whereas 40% of all expenditure engaged by the health ministry goes to the richest 20% of the population [12]. Health insurance covers only 16% of the population and nearly exclusively in cities. This percentage is expected to increase to 32% of the population under the new law on Compulsory Health Insurance supposed to be applicable by 2006. According to the World Health Organisation and using the Health Adjusted Life Expectancy at birth (HALE) which excludes years of illness, the expectation of lost healthy years at birth is 11.9 years for women vs. 9.4 for men, which shadows the relative high rates of life expectancy [2] (Table 6). In 1999, the percentage of the population with sustainable access to affordable essential drugs was estimated to be between 50 and 79%. A more precise estimate was given by the national survey on living standards conducted by the statistical department of the planning ministry in 1998–99 concluding that more than 33% of the population is unable to afford necessary medical care. The inequity is more exacerbated in rural areas where this percentage reaches 44 % (Table 7). Inequities also exist for the free access to public structures since the richest are more likely to get free care than the poorest [11]. Households devote on average 6.5% of their budget to health care. This percentage becomes 9% for the poorest 20% whereas it represents 3.9% for the richest 20%. With 19% of the population living under the threshold of poverty and the consequences of a multi-dimensional transition, health care is becoming less and less affordable. For instance, the cost of care and treatment for an insulino-dependent diabetic person is estimated at USD120 per month [13]. This is nearly the monthly wages of a non-qualified manual worker, and this is not to mention the cost of treatment for other conditions like heart disease, kidney failure and cancer.

With these inequities and such an ill-health system, Morocco is facing the double burden of communicable and non-communicable diseases [14‐16].

Non-communicable diseases (NCDs) are responsible for 55.8% of the total Disability Adjusted Life Years (DALYs). Cardio-Vascular Diseases, cancer, respiratory diseases and diabetes are the main contributors. The prevalence of the main cardiovascular risk factors was considered in a study conducted in 2000 on a representative sample aged 20 years and over [17]. According to this study, the prevalence of hypertension, hyper-cholesterolaemia and diabetes were respectively 33.6%, 29% and 6.6%. The prevalence of obesity was markedly higher in females in urban areas with 40% of women overweight and an average body mass index (BMI) of 25.6 kg/m² versus 23.8 kg/m² for males.

The incidence and mortality of cancer are increasing, especially for breast, lung, cervical, colorectal and stomach cancer which represent altogether 42% of all new cases and 44% of all deaths caused by cancer.

The morbidity caused by Communicable Diseases (CDs), perinatal and maternal represents 33.4% of DALYs. Despite the progress achieved in the control of preventable childhood diseases, schistosomiasis, and the relatively low incidence of HIV/AIDS, Morocco is still facing a growing burden of infective diseases. In particular, sexually transmitted diseases and environmental related diseases such as tuberculosis, typhoid, viral hepatitis, trachoma and conjunctivitis have been persistent or increasing during the last six years [18].

Preventive measures and early detection should reduce significantly the impact of CDs and NCDs. As indicated earlier, however, the current ill-health system, with insufficient infrastructure, lack of human capacities and bad governance is unable to cope with the growing burden of disease.