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Advances in Social Sciences Research Journal – Vol.9, No.10
Publication Date:October 25, 2022
DOI:10.14738/assrj.910.13336.
Loudghiri, K., &Fazouane, A. (2022). Effects of Health Policy on Children’s Physical Well-being in Morocco.Advances in Social
Sciences Research Journal, 9(10). 496-519.
Services for Science and Education – United Kingdom
Effects of Health Policy on Children’s Physical Well-being in
Morocco
Khadija Loudghiri
Laboratory in Gender, Economy, Actuarial, Statistics
Demography and Sustainable Development (GEAS3D)
National Institute of Statistics and Applied Economics (INSEA)
Avenue Allal El Fassi, B.P.:6217 Rabat-Instituts, Rabat, Morocco
AbdesselamFazouane
Laboratory in Gender, Economy, Actuarial, Statistics
Demography and Sustainable Development (GEAS3D)
National Institute of Statistics and Applied Economics (INSEA)
Avenue Allal El Fassi, B.P.:6217 Rabat-Instituts, Rabat, Morocco
ABSTRACT
Several international studies published by the authors and global bodies have
highlighted the important role of child health policies in achieving the Sustainable
Development Goals (SDGs). In this article, we examine the impact of health policy
on child wellbeing in Morocco. To evaluate child health progress, the Millennium
Development Goals, indicators, and goals have been adopted. Moroccan children
have been the focus of several health strategies, programs and plans developed by
the Ministry of Health within the framework of the five-year and three-year
development plans. Other government departments have also developed plans for
children and young people. However, these strategies, programs, and plans have
been subject to many structural dysfunctions and have therefore not been able to
achieve their intended objectives. Accordingly, the findings are consistent with the
indicators and determinants of Moroccan children's health, which show that
certain aspects of their health have gaps due to inadequate governance. In
conclusion, and in view of the results of these strategies, programs and plans, it
appears that Morocco does not yet have a genuine, comprehensive, effective and
efficient child health policy.
Keywords: policy, health, child, well-being, Morocco.
INTRODUCTION
No doubt that the child has a right to well-being. The child well-being was addressed from
several angles and areas, especially health and education. For example, an interdisciplinary
form of health promotion was developed in 2010 by the Center on the Developing Child at
Harvard University. This form includes biology of health, basics of health, caregiver and
community capacities, and policy and program levers for innovation. The combination of all
these factors will lead to the creation of a frame that will develop physical as well as mental
wellbeing [1].
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Loudghiri, K., &Fazouane, A. (2022). Effects of Health Policy on Children’s Physical Well-being in Morocco.Advances in Social Sciences Research
Journal, 9(10). 496-519.
URL: http://dx.doi.org/10.14738/assrj.910.13336
Stebletsova and Scanlan (2018) concludes that “The interrelatedness of the various influences
to child wellbeing highlights the necessity of a not just medical intervention to support child
wellbeing but also requires policies in a range of other areas, such as public health, early
childhood education, child welfare, mental health, primary health care, workforce
development, housing, urban planning and many others”.
The term health policy refers to all the strategic decisions made by public authorities to
improve the health of populations. The aim is to provide everyone with the means to treat
themselves and to remain healthy for as long as possible. Accordingly, health policy sets
objectives to be achieved, establishes priorities, defines intervention areas and decides on
plans, programs, and means of implementing them.
Historically, public health policies have been around since ancient Egypt, Mesopotamia,
ancient China, ancient Greece, and Rome. In addition, no one can deny that during the Middle
Ages, scholars from the Muslim world contributed greatly to medical science. Finally, the
development of scientific medicine in the West during the seventeenth and eighteenth
centuries made possible, among other things, containment of the great plague epidemics in
Europe, reduction of famine, creation of hospitals, teaching of medicine, Vaccine discovery,
practice of vaccination, and adoption of public and private hygiene measures [2] [3].
But it was only after the first conference on health promotion, organized in Ottawa, Canada,
by the World Health Organization (WHO) on 17-21 November 1986 that the need for public
health policy was affirmed. According to Tizio[4], health policy plays a crucial role in ensuring
sustainable development processes.
Several countries have adopted global health plans based on health determinants. Other
approaches have focused either on targeting a specific public (early childhood, women, etc.)
or on themes (nutrition, chronic diseases, communicable diseases, etc.) or places of life
(schools, factories, etc.). Following this view, several concepts have arisen, such as social
medicine, ethical values, equity, health promotion, health education, etc[5].
Protecting maternal and child health is generally the top priority of public health policies. In
addition, the health of the mother is very closely related to the health of the child. Berk [6]
affirmed that the child’s health starts with the health of the forthcoming mother before she
becomes pregnant. Children's health is defined as their physical and mental well-being from
birth to 18 years of age.
APHA [7] recommends that child health policies should be based on the following principles:
meet children's basic needs for food, shelter and safety;
the physical, emotional and developmental health of children depends on the health of
their entire family;
the health and safety of children is strongly influenced by the physical environment;
all children need social support;
children must have access to comprehensive, developmentally appropriate health care
that is accessible, continuous, comprehensive, coordinated and family-centered;
special care must be provided for the most vulnerable children;
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a national commitment to the health of children abroad is required.
In addition, the Millennium Summit was held at United Nations (UN) Headquarters in New
York in 2000. At the summit, 189 member states, including Morocco, adopted a Millennium
Declaration containing eight Millennium Development Goals (MDGs) with a view to achieving
them by the end of 2015. Three of these relate to maternal and child health: reduce under-5
mortality (Goal 4), improve maternal health (Goal 5), and combat HIV/AIDS, malaria and
other diseases (Goal 6). However, the other five goals also indirectly affect maternal and child
health: poverty (Goal 1), education (Goal 2), gender and women's empowerment (Goal 3),
environment (Goal 7), development partnerships (Goal 8).
One of the main challenges highlighted by the Millennium Development Goals is developing
health strategies that meet the different and changing needs of countries. This will involve
designing cost-effective strategies that focus on the diseases and conditions that account for
the largest share of the disease burden.
Despite some regional differences, the results of these initiatives at the international level
have been satisfactory. As a result, in 2017, the under-5 mortality rate ranged from 0.2% to
15.6%. Measles, neonatal tetanus, diarrhea and respiratory diseases were the most significant
reasons for the decline in mortality. Although causes related to congenital malformations,
premature birth and malaria have increased [8].
Finally, there's the question of Morocco. Are Moroccan youngsters physically active and
healthy? Is Moroccan public health policy reaching all children? Is it possible that the
government should do more to protect the physical well-being of particular groups of
children? Prior to answering these issues, it is vital to explain the study's data and
methodologies, as well as Moroccan child health policy initiatives.
DATA AND METHODS
Most research on well-being and family well-being in particular are based on
multidimensional models. They choose appropriate domains and different indicators to
measure them. However, it appears that these studies are guided more by the results of
previous research, policy interests and available data than by theory. Indeed, in the absence of
a guiding theory, the choice of these domains and indicators is determined by the subjectives
and preferences of researchers, funders or policy makers [9].
In the physical well-being literature, several approaches have been adopted and several
indicators have been chosen. Wollny et al. [9] summarized these latter as: access to and
quality of health care; satisfaction with health care services; physical health/health status;
nutrition; parents’ level of fatigue; substance use; disability; healthy lifestyle; ability to afford
medical care.
Maternal and child health was at the center of the MDGs as it was included in three of the
eight goals and was crucial to achieving the other goals, including ending extreme poverty and
hunger, promoting education, and achieving gender equality. It was also a valuable indicator
of well-being.
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Loudghiri, K., &Fazouane, A. (2022). Effects of Health Policy on Children’s Physical Well-being in Morocco.Advances in Social Sciences Research
Journal, 9(10). 496-519.
URL: http://dx.doi.org/10.14738/assrj.910.13336
To carry out our study, we have chosen a descriptive quantitative research methodology
based on the collection of information relating to the health of Moroccans in general and to
child and maternal health in particular. This information comes from national surveys carried
out by the Ministry of Health. These are the National Population and Health Survey (ENPS II- 1992), the National Population and Family Health Survey (ENPSF-2011) and the National
Population and Family Health Survey (ENPSF-2018). The results of these surveys are
published in open access on the website of this ministry. We also consulted a database of the
High Commission of Plan published in open access too on its site web.
In terms of objectives and measurement, we have opted, firstly, for the targets and
measurement indicators defined in the MDGs. We have aligned the achievements of the
Moroccan child and maternal health policy with the targets of the MDGs while using the said
measurement indicators to identify the strengths and weaknesses of the policy actions. Then,
we have tried to measure the physical well-being according to indicators as cited above by
Wollny et al. [9]. But we have selected only those that have a direct link to child health policy.
However, our research had some limitations for the two approaches. For example, some
information was missing (HIV prevalence rate among pregnant women aged 15-24, Orphans'
school enrolment ratio compared to other non-orphaned children aged 10-14 years, etc.).
Based on the available information, the start and end years of the MDGs, namely 1990 and
2015, do not precisely coincide with 1992 and 2018. Furthermore, the national surveys ENPS
II-1992, ENPSF-2011 and ENSPF-2018 did not include the indicators adopted by the MDGs.
Given these limitations in available data, the search for further information on Moroccan child
health policy was essential. It is clear that, in general, there were few basic options for filling
the gaps in special data on children. Nevertheless, we were able to link data from multiple
sources relating to the physical and mental well-being of Moroccan children. Indeed, national
and international scientific publications, reports of the national bodies, those of the
international organizations (UN, WHO, Unicef) and those of the central departments of the
Ministry of Health, have been taken into consideration.
MOROCCAN CHILD HEALTH POLICY ACTIONS
At the outset of this section, it should be noted that the context of the study was described in
Annex 1. Also, the Health System and Care offers in Morocco were described too in Annex 2.
Morocco has been interested in health policy since its independence. King Mohammed V
stated during the First National Health Conference in Casablanca in April 1959 that "to be
effective, a health policy must be part of a general government policy".
1981 was also a turning point in the field of health in Morocco. In effect, the Moroccan health
policy implemented in the country was aligned with the declaration of the International
Conference on Primary Health Care in Alma Ata (USSR) in 1978. It was into line too with the
resolutions of the World Health Assemblies of 1977 to 1981, namely achieving the goal of
Health for All.
Additionally, Morocco ratified the International Convention on the Rights of the Child in 1993,
and has therefore paid particular attention to vulnerable populations, especially children. In
the beginning, health policy for Moroccan children focused primarily on those under the age
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of five. From 2004, other children between the ages of 6 and 18 will also be taken care of. So,
from 1978 to 1997, four main specific programs and a strategy for children were
implemented.
Furthermore, Morocco has implemented a national action plan for children to improve their
lives for the period 2005-2015, based on the Millennium Development Goals (MDGs) adopted
in 2000.
Since independence, Morocco has used the planning method. This period is characterized by
several measures formulated in the three-year and five-year economic and social
development plans aimed at improving the health of citizens in general, and children in
particular.
During this time period, several programs aimed at improving the health status of children
were also adopted. Programs like these have significantly reduced infant and child mortality
rates from 138% in 1979-80 (National Fertility and Family Planning Survey, Ministry of
Health, 1979-80) to 47% in 1997. These programs are as follows: National Immunization
Program; Program for the Control of Deficiency Diseases; Diarrheal Disease Control Program;
Acute Respiratory Infections Program; Integrated Management of Childhood Illness Strategy
and National School and University Hygiene Program.
From 2003 onwards, many plans and programs were adopted (see Appendix 3).
RESULTS
Achievement of the MDGs Targets
As noted above, we have aligned the achievements of the Moroccan child and maternal health
policy with the MDGs targets. Based on its measurement indicators, we have found the
following results (Table 1).
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Loudghiri, K., &Fazouane, A. (2022). Effects of Health Policy on Children’s Physical Well-being in Morocco.Advances in Social Sciences Research
Journal, 9(10). 496-519.
URL: http://dx.doi.org/10.14738/assrj.910.13336
Table 1. Moroccan realizations of the MDGs goals and targets according to their indicators.
MDGs Goals MDGs Targets MDGs Indicators Moroccan
percentage
Period
and/or
source
Percentage
of
achievement
4. Reduce
under-five
mortality
5. Reduce by
two-thirds,
between 1990
and 2015, the
mortality rate
for children
under-five
mortality rate.
13. Under-five
mortality rate
76.1‰ (ENPS II- 1992) 70.82%
22.2‰ (ENPSF-2018)
14. Infant
mortality rate
57.3‰ (ENPS II- 1992) 68.58%
18.0‰ (ENPSF-2018)
15. Proportion of
1-year-olds
immunized against
measles
69.8% (ENPS II- 1992) 33.38%
93.1% (ENPSF-2018)
5. Improve
maternal
health
6. Reduce by
three quarters,
between 1990
and 2015, the
maternal
mortality ratio
16. Maternal
mortality rate
332 per
100,000 live
births
(1990-1991) /
(ENPS II- 1992) 78.13% 72.6 per
100,000 live
births
(2015-2016) /
(ENPSF-2018)
17. Proportion of
births attended by
skilled health
personnel
29.8%
(1987-1991) /
(ENPS II- 1992) 190.60%
86.6% (2013-2017) /
(ENPSF-2018)
6.
Combating
HIV/AIDS,
malaria and
other
diseases
7. Have halted
by 2015 and
begun to
reverse the
spread of
HIV/AIDS
18. HIV prevalence
rate among
pregnant women
aged 15-24
0.1%
(1990) /
(World Bank,
2020) 00%
0.1%
(2020) /
(World Bank,
2020)
19. Contraceptive
prevalence rate
66% (ENPS II- 1992) 7.27%
70.8% (ENPSF-2018)
20. Orphans'
school enrolment
ratio compared to
other non- orphaned children
aged 10-14 years
Data not
available -- --
8. By 2015,
have halted and
begun to
reverse the
incidence of
malaria and
other major
diseases
21. Malaria
prevalence and
mortality rates
No
indigenous
cases of
malaria have
been
reported in
Morocco
since 2004
(WHO, 2010)
Morocco was
certified by
WHO in May
2010 as
having
eradicated
indigenous
malaria
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22. Proportion of
population living
in malaria risk
areas using
effective malaria
protection and
treatment
Idem -- Idem
23. a) Tuberculosis
prevalence
110 cases per
100,000
inhabitants
(2000) /
(Ministry of
Health,
Epidemiology,
2015) 17%
89 cases per
100,000
inhabitants
(2015) /
(Ministry of
Health,
Epidemiology,
2015)
23. b) Mortality
rate
25 per
100,000
inhabitants
(1990) /
(Ministry of
Health,
Epidemiology,
2018) 59%
8.1 per
100,000
inhabitants
(2018) /
(Ministry of
Health,
Epidemiology,
2018)
24. Proportion of
tuberculosis cases
detected and
treated under
DOTS (Directly
Observed
Treatment Short
Course)
90%
(1998) /
(Ministry of
Health,
Epidemiology,
2018) -4.44%
86%
(2017) /
(Ministry of
Health,
Epidemiology,
2018)
MDGs Source: WHO, 2005. Health and the Millennium Development Goals.
Morocco has successfully achieved target 5 in infant mortality and under-five mortality. As
well as considering the ENPS-2011, the mortality rate among children under 5 years of age
has decreased by 27% (22.20 deaths per 1,000 live births in 2018 compared to 30.5 deaths
per 1,000 live births in 2011). Also, the infant mortality rate has decreased by 38% (18.0
deaths per 1,000 live births in 2018 compared to 28.8 deaths in 2011). In addition, the
neonatal mortality rate decreased by 38% (13.56 deaths per 1,000 live births in 2018
compared with 21.7 deaths in 2011). There was also a decrease in the mortality gap between
rural and urban areas, particularly for infant mortality (6.7 points in 2018 compared with 10
points in 2011).
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Loudghiri, K., &Fazouane, A. (2022). Effects of Health Policy on Children’s Physical Well-being in Morocco.Advances in Social Sciences Research
Journal, 9(10). 496-519.
URL: http://dx.doi.org/10.14738/assrj.910.13336
Fertility has declined noticeably over the past decades (7 children per woman in 1962 to 2.4
children per woman in 2018). As a result, the monitoring of pregnancies, the improvement of
delivery conditions, the care and monitoring of newborns, vaccination, etc. have all played a
part in reducing maternal, prenatal and infant morbidity and mortality between 2004 and
2018 [10][11].
In 2018, the percentage of children aged 12 to 23 months who were fully immunized
(received all vaccines of the National Immunization Program) increased from 87.7% in 2011
to 91% in 2018. In 2002, neonatal tetanus was eliminated and other diseases, such as
diphtheria, were controlled.
Morocco also achieved target 6 in the area of maternal mortality. The maternal mortality rate
decreased from 332 deaths per 100,000 live births in 1990-1991 to 72.6 deaths per 100,000
live births in 2015-2016, a reduction of 78.13%.
HIV/AIDS (target 7) continues to spread despite the low incidence rate which has stagnated
for almost three decades.
Among the major diseases (target 8), Morocco has been able to combat tuberculosis and thus
reduce its mortality rate.
The Physical Well-being of Moroccan Children according to other Indicators [9]
In this approach, and due to lack of available data, we therefore selected the indicators for
which information was available.
Access to and Quality of Health Care
There are inequalities in health care coverage for children in the Moroccan health system,
whether between regions, between rural and urban areas, or on a socioeconomic basis.
Geographically, there is difficulty in accessing health care and services, particularly in rural
and isolated areas. In fact, a quarter of the Moroccan population lives more than 10 kilometers
from a health facility. Also, there is a strong inequality in the use of health care according to
income, expenditure and the presence of social security coverage. In addition, the national
neonatal screening program for congenital hypothyroidism, developed in 2012, is only
practiced in five regions out of twelve [12] [13] [14] [15].
Despite the adoption of a national pharmaceutical policy in 2015, the medicines sector also
faces problems related to production (dominance of the private sector, national production at
70%), supply (irregularities in the expression of needs, diversity of purchasing procedures,
delays in delivery, lack of an information system, etc.) and marketing (high prices, economic
inaccessibility, narrow local market, low export rate, etc.). Also, the distribution of dispensing
pharmacies does not cover the entire national territory. In fact, the majority of these
pharmacies are concentrated on the Kenitra-El Jadida axis on the Atlantic Ocean and, as a
result, several communes, especially the most isolated, remain under-equipped [13].
It was also noted that the prices of medicines in Morocco, despite the various reductions
made, are very high. More than that, for a single medicine, there are several brands and
several prices depending on the sales channel (pharmacy, hospital, etc.). A comparison
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Loudghiri, K., &Fazouane, A. (2022). Effects of Health Policy on Children’s Physical Well-being in Morocco.Advances in Social Sciences Research
Journal, 9(10). 496-519.
URL: http://dx.doi.org/10.14738/assrj.910.13336
The percentage of exclusive breastfeeding, recorded in 2018, among children under six
months of age, is 35% and remains even lower. The stunting increased from 14.9% in 2011 to
15.1% in 2018 (20.5% in rural areas and 10.4% in urban areas) and a prevalence of 17.3% for
boys against 12.7% for girls. Also, wasting increased from 2.3% in 2011 to 2.6% in 2018
(2.7% in rural areas versus 2.5% in urban areas and 2.4% for boys versus 2.8% for girls).
Also, there is severe iodine deficiency in children from mountainous regions. As for
overweight, it remained practically unchanged between 2011 and 2018 (10.7% against 10.8%
at national level). This rate is 11.7% for urban dwellers and falls to 9.7% for rural dwellers.
Similarly, it is 12.3% among boys against 9.2% among girls. These observations confirm the
non-achievement of the expected results of child and maternal health strategies [12][17] [18]
[15] [20].
Micronutrients are also important for the brain, bones, and overall health as key components
of a well-balanced diet. Any shortage has the potential to cause irreversible harm (stunted
growth or cognitive development). The major method for combating micronutrient deficits in
children is vitamin A and D supplementation. All basic health-care facilities provide these
vitamins free of charge. They are given to youngsters under the age of two years old in
accordance with the national supplementation schedule. From the sixth month of life, three
doses of vitamin A are given every six months, and two doses of vitamin D are given every six
months during the first six months.
Disability
There are 168,410 disabled children, accounting for 7.6% of the total disabled population of
2.2 million. Major difficulties in the medical and social care of children with disabilities (i.e.,
lack of early detection of pathologies causing disability) [15].
Healthy Lifestyle
The rate of urbanization has risen dramatically as a result of the large rural exodus (30% in
1960 to 68% in 2020). Moroccan houses house 56.8% of children and their families, whereas
rural housing houses 22.8% and flats house 11.6%. 17.6% of children live in households with
more than three persons per room, and 19.1% live in homes with roofs and flooring built of
inadequate materials. 86.3% of the country's drinking water was supplied through the
network. Electricity is available to 98.5% of households. Only 65.1% of the population has
access to sewerage [15] [20].
In 2018, the average age of first marriage for women was 25.4 years. Minors (under the age of
18) applied for 32,104 marriages in the same year (99% were girls). These applications were
accepted in 81.7% of cases. The average number of individuals in a household is 4.6. Data
from the Population and Housing Census (RGPH-2014) shows that women lead 16.2% of
households [15][20][21].
This suggests a debt overhang, which mortgages the futures of future generations. The Gross
Domestic Product (GDP) is expected to grow at a pace of 5.19% in 2021. The
multidimensional poverty rate in the United States was 6.1% in 2013. The rate in urban areas
is 1.2%, whereas it is 13.5% in rural areas. The rate for children under the age of 18 in 2014
was 11% [15] [20].
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The unemployment rate in 2019 was 9.2%. The rate in metropolitan areas is 12.9%, whereas
it is 3.7% in rural areas. 26.5% of 15- to 24-year-olds, 13.5% of women, and 21.6% of college
graduates are affected [20].
Ability to afford Medical Care
Most health expenditures are borne by households. The proportion of total health
expenditures has fallen from 50.7% in 2013 to 45.6% in 2018. This percentage increases to
59.7% if we include the annual contributions made by these households to the health
insurance authorities. Therefore, Moroccan households remain the main funders of the
country's health system. When compared to countries at a similar level of development,
Morocco's rate is still relatively low (Figure 1). As an indication, "WHO suggests that health
expenditure is considered catastrophic when it reaches or exceeds 40% of non-essential
household income, i.e. the budget remaining after basic needs are met" [22].
Figure 1. Comparison of out-of-pocket payments for health expenditure in Morocco with
similarly developed countries – 2018
Source: Ministry of Health & WHO (2018).
Additionally, it should be noted that the state has fulfilled its responsibility in the area of
health care expenditures, which it had at the time of independence. Local authorities were
responsible for the healthcare costs of the population under the communal charter of 1959.
The 1976 communal charter changed this and restricted this responsibility to hygiene and
sanitation [23].
The social protection system, with its two schemes, covers only 62% of the population, in
addition to the 5% covered by private insurance. 33 % of the population, mostly in the
informal sector, do not have social protection, which means they have extremely low health
expenditures [24].
DISCUSSION
According to Mekonen[25], Morocco ranked 4th out of 52 countries with a score of 0.821 in
regard to putting in place legal and policy frameworks to protect children from harm and
exploitation. By comparison, Tunisia and Algeria ranked 16th and 24th with scores of 0.738
and 0.690, respectively, among countries at the same economic level. The Moroccan budget,
however, came in 15th with a score of 0.532, trailing Tunisia (6th: 0.591) and Algeria (12th:
0.560). Additionally, Morocco comes in 9th in terms of achieving children-related outcomes
after Libya (1st place: 0.766), Tunisia (4th place: 0.736) and Algeria (6th place: 0.676). Even so,
the aforementioned ranking does not accurately reflect the health status of Moroccan children
according to some key indicators in 2018 (Table 2).
0
50
Morocco Iran Tunisia Jordan Lebanon
Direct payments by households (%)
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Loudghiri, K., &Fazouane, A. (2022). Effects of Health Policy on Children’s Physical Well-being in Morocco.Advances in Social Sciences Research
Journal, 9(10). 496-519.
URL: http://dx.doi.org/10.14738/assrj.910.13336
Table 2. Main indicators of child health status in Morocco (2018)
Indicators Value
Life expectancy at birth (in years) 76
Neonatal mortality rate (per 1,000) 13.56
Infant mortality rate (per 1,000) 18
Infant mortality rate (under 5 years) (per 1,000) 22.2
Maternal mortality ratio (per 100,000 live births) 72
Rate of stunted children under 5 years of age (%) 15
Full immunization of children aged 12-23 months (%) 90.6
Acute malnutrition in children under 5 (%) 2.6
Exclusive breastfeeding in children under six months (%) 35
Source: Ministry of Health, 2018; UNICEF 2019; HCP, 2019.
However, the Ministry of Health was criticized for focusing most of its health programs on
mothers and young children. As other programs focused on adolescent issues (10-19 years),
children aged 6-9 years were almost exclusively covered by the National School and
University Health Program [15].
These plans and programs mentioned above had several problems and shortcomings in their
governance, which limited their success (overlapping, lack of participation, lack of cohesion,
lack of quality assurance, slow procedures, lack of continuity, lack of scientific research on
their impact, inactivity of the health map, lack of evaluation and monitoring, lack of
transparency, conflicts of interest, lack of accountability, etc.). Historically, most failures have
been caused by the accumulation of plans without a unified and coherent vision between
them [19] [25].
The importance of monitoring and evaluation mechanisms, including quality mid-term and
final evaluations measured against well-defined benchmarks, cannot be overstated. It is their
vital and imperative role, on the one hand, to measure the degree of realization of these plans
and programs and, on the other hand, to make any necessary adjustments and readjustments.
Planning future plans and programs requires them as well.
Nevertheless, these evaluations, whenever they were conducted, failed to produce reliable
results, as in the report of the final evaluation of the UN Development Assistance Framework
for Morocco 2012-2016 (UNDAF), which made the following observation: "It should also be
indicated that the vertical and horizontal logic of the results matrix has been respected even
though, in several places, indicators do not have a baseline situation, which makes analysis
difficult and several outputs do not have indicators or sufficient indicators to measure the
achievement of the output" [26] (p. 26). This situation was also highlighted by the WHO in
2012, which said that the five-year health plans had not been evaluated [25].
Despite the various child health strategies adopted by Morocco, the numerous plans and
programs implemented, the ambitious objectives defined and the notable advancements
made, inequalities persist on multiple levels.
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True, the State's efforts have succeeded in changing the way the health system is handled, as
well as building a more suitable application and implementation mechanism at the
organizational and institutional levels:
• establishing health-care-expansion programs;
• maximizing the effectiveness of human resources;
• promoting medical research and education;
• and enlisting the help of the private sector to provide care.
Nonetheless, the state is unable to fill certain gaps, such as:
a lack of a cross-cutting and integrated approach;
the Moroccan health and child protection system still has gaps (lack of a cross- cutting and integrated approach, dominance of the medical and curative logic,
an ineffective regionalization process, sectoral strategies unsuited to the needs
of several categories of vulnerable children, etc.);
health strategies and those of the other departments concerned do not take into
account the social determinants of child health (poverty, insalubrious, social
protection, illiteracy, access to pre-school education, school drop-out, etc.).
Another very important aspect is the presence of constraints and weaknesses in the
governance of the health system (difficulties with implementing action plans, inadequate
information systems, inadequate communication strategies, insufficient human resources,
inappropriate or missing legal and regulatory texts, etc.). In light of this, it is worthwhile
noting that the Ministry of Health published a document in 2013 entitled: "For a New
Governance of the Health Sector". Providing access to health care for all Moroccans and
building an efficient health system was the goal of this government document. It included
three main axes and nine strategic areas for improving the health sector's governance [23].
Furthermore, in Morocco, health strategies, especially those for children, have always been
influenced by the economic performance of the country. The Moroccan economy has always
been vulnerable to climatic hazards, so a year of drought automatically impacts all sectors,
including social life, as well. Meanwhile, they also depend on the general orientations of the
country's economic and social policy, which sometimes attempted to redress the fundamental
imbalances in finance, euro currency and budget, causing significant social imbalances [12]. In
addition, Tizio[4] confirmed this by citing the failure of several African countries'
development policies, including their health systems, due to the "Bamako Initiative".
According to him, liberal health policies failures demonstrate that they were, arguably,
inappropriate to the context of countries that applied them.
Morocco's health policy also has another shortcoming, and this is where the problem lies: the
total budget allocated to the sector is still below the expectations of the population. According
to the 1997 State budget, expenditures for basic social services amounted to 17.2% (12.2
billion dirhams1). In this sum, 85% went to basic education, while only 10% went to health.
Water (3.9%), sanitation (0.7%), and literacy (0.08%) made up the remaining 5% [12].
1
The dirham is the monetary unit of Morocco, its exchange rate is 9.23 dirhams for 1 US dollar.
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Figure 5. Comparison of Morocco's paramedical density rate with countries of similar
development - 2017-2018
Source: World Bank (2017-2018)
Morocco's low international position on the Human Development Index is mainly due to its
health system's flaws (HDI). Morocco was placed 123rd out of 188 nations in 2018, behind
Tunisia and Algeria, who were ranked 97th and 83rd, respectively. It rose to 121st rank out of
189 nations in 2020 [20] [33].
CONCLUSION AND RECOMMENDATIONS
There exist programs and action plans for child and maternal health, according to this study,
but they are vulnerable to change following each ministerial reshuffle. It also mentioned
structural issues that obstruct the smooth running of these programs and their
implementation (poor availability of human and financial resources, the isolation of certain
regions, the absence of a participatory approach by communities and local authorities, the
lack of coordination with actors in the field of health, poor decentralization of decision- making power, the high rate of illiteracy, the rate of poverty, discrimination in terms of
gender, etc).
Despite the positive outcomes of these health initiatives and policies, health indicators
suggest that Moroccan children continue to suffer from a variety of ailments (mortality,
morbidity, malnutrition, wasting, obesity, stunted growth, non-communicable diseases, etc.).
After all, it would be prudent for Morocco to develop a true national child health policy in the
future, with the active participation of various social actors and health professionals from
both the public and private sectors, within the context of a comprehensive, integrated,
planned, and well-regulated health system.
It is also vital to have good health-care governance. It must be founded on concepts of
participation, collaboration, decentralization, regionalization, democracy, and the rule of law,
as well as transparency, impartiality, complementarity, and mutuality. First and foremost, this
governance must address three important issues: finance, human resources, and litigation
ability.
In sum, Tizio[4] summarized the major role of health policy in the following paragraph: "A
health policy contributes to sustainable development under certain conditions which are
simultaneously related to an improvement in the productive efficiency of the system, the
0
10
20
30
Jordan Iran Tunisia Lebanon Morocco
Paramedical density per 10000 inhabitants
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[15] UNICEF, ONDH & ONDE. Situation des enfants au Maroc. Analyse selon l’approche équité. 2019, 180 p.
https://www.unicef.org/morocco/media/2046/file/Situation%20des%20enfants%20au%20Maroc%202019.p
df
[16] Chamber of Representatives. Rapport de la Mission d’Information sur le Prix du Médicament au Maroc.
Commission des Finances et du Développement Economique, 2009, 71 p.
https://pharmacie.ma/uploads//pdfs/Rapport_de_mission_v41_0_Francais.pdf
[17] Ministry of Health. PlanSanté2025. Biland’étape(mai2018- mai 2019).Direction de l’Epidémiologie et de
Lutte contre les Maladies, 2019, 82 p.
https://www.sante.gov.ma/Documents/2019/06/Bilan%20d%E2%80%99%C3%A9tape%20DELM.pdf
[18] Ministry of Health. Plan Santé 2025. Bilan d’étape (mai 2018 - mai 2019). Direction de la Population, 2019, 46
p. http://www.sante.gov.ma/Documents/2019/06/Bilan%20d%E2%80%99%C3%A9tape%20%20DP.pdf
[19] Ministry of Health& OMS. Evaluation des fonctionsessentielles de santé publique auMaroc. Rapport technique,
2016, 71 p. https://www.sante.gov.ma/Documents/2016/02/3%20Rapport%20Evaluation%20FESP.pdf
[20] High Commission for Planning (HCP). Les IndicateursSociaux du Maroc - 2019. 329 p., 2020.
file:///C:/Users/pc/Downloads/Les%20Indicateurs%20sociaux%20du%20Maroc,%20Edition%202020.pdf
[21] Ministry of Health& OMS. Comptes nationaux de la santé-2018. 113 pp., 2018.
https://www.sante.gov.ma/Publications/Etudes_enquete/Documents/2021/CNS-2018.pdf
[22] WHO. Health and the Millennium Development Goals. 2005. ISBN 92 4 256298 6. 84 p.
https://www.who.int/hdp/publications/mdg_fr.pdf
[23] Ministry of Health. Livreblanc. Pour une nouvelle gouvernance du secteur de lasanté. 2ème Conférence
Nationale de la Santé (Marrakech, 1, 2 et 3 juillet 2013), 64 pp. http://sehati.gov.ma/uploads/LivreBlanc_1_1.pdf
[24] National Human Rights Council. Le Droit des enfants à la santé au Maroc. Rapport. 2015.
https://www.ohchr.org/Documents/Issues/Children/Study/RightHealth/CNDH_Maroc.doc
[25] Mekonen, Y. Measuring Government Performance in Realising Child Rights and Child Wellbeing: The Approach
and Indicators.Child IndicatorsResearch, n° 3, 2010, 205–241. https://doi.org/10.1007/s12187-009-9047-5
[25] OMS. Examen du système de santé au Maroc : défis et opportunités pour accélérer les progrès vers la
couverture sanitaire universelle. De l’engagement politique à la mise en œuvre d’une politique de santé. BRMO.
Rapport. EM/HEC/040/F, 2012, 45 p. http://hdl.handle.net/2268/209418
[26] United Nations. Evaluation finale de l’UNDAF Maroc 2012-2016.Rapport final, 2016, 130 p.
https://www.undp.org/.../UNCT-MA-Rapport%20EFI%20UNDAF%202012- 2016%20Maroc_VF.pdf
[27] UNICEF, CEDHD. La Situation des Enfants au Maroc. Analyse selon l’approche basée sur les droits humains.
Pour un Maroc digne de ses enfants, 2007, 129 p. http://cedhd.org/wp-content/uploads/2019/05/32.pdf
[28] Royal Institute for Strategic Studies (IRES). Evolution du positionnement international duMaroc. Tableau de
bord stratégique (8ème édition), 2020, 184 p. https://www.ires.ma/fr/publications/rapports- g%C3%A9n%C3%A9raux/7469-tableau-de-bord-strat%C3%A9gique,-evolution-du-positionnement- international-du-maroc-huiti%C3%A8me-%C3%A9dition.html
[29] Olivier de Sardan, Jean-Pierre &Ridde, Valéry. Les spécificités des politiques publiques et des systèmes de santé
en Afrique sahélienne.Centre de ressources, United Cities and Local Governments of Africa, 2014, pp. 15-30.
https://knowledge.uclga.org/IMG/pdf/lesspecificitesdespolitiquespubliquesetdessystemesdesanteenafriquesah
elienne.pdf
[30] Pressman, Jeffrey L., and Aaron B. Wildavsky. How great expectations in Washington are dashed in Oakland.
University of California: Berkeley, LA, USA, 1973.
[31] Saetren, Harald. Facts and myths about research on public policy implementation: Out-of-Fashion, allegedly
dead, but still very much alive and relevant. Policy Studies Journal 33.4, 2005: 559-582.
[32] Lafaye, Caroline Guibet. L’épigénétique : pour de nouvelles politiques de santé
?HumanistykaiPrzyrodoznawstwo, 2014, p. 4-22. hal-00983182 https://hal.archives-ouvertes.fr/hal- 00983182/document
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Journal, 9(10). 496-519.
URL: http://dx.doi.org/10.14738/assrj.910.13336
[33] OXFAM. Un Maroc égalitaire, une taxation juste. Rapport, 2019, 54 p.
https://www.oxfam.org/fr/publications/un-maroc-egalitaire-une-taxation-juste
APPENDIX 1: CONTEXT OF THE STUDY
Subject Data Details
Geographical location Northwestern Africa
Area 710,850 square kilometers
Maritime coastline 3,500 kilometers
- Atlantic coast: 2,934
km
- Mediterranean
coast: 512 km
Land borders Algeria (east), Mauritania (south) &
Europe (north).
Spain and the Strait of
Gibraltar: 15 km from the
Mediterranean coast.
Population 36 million
- Women: more than
50%
- Children under 18
years: 11.2 million
(5.5 million girls &
5.7 million
boys)(2019)
Economy
The growth of the national economy
has been disrupted over the past
decade
- 3.3% (2012)
- 4.1% (2017)
- 3% (2018)
- 2.9% (2019)
- 4.3% (2021)
Human development
ranking
- Human Development Index
(121)
- Prosperity and Welfare Index
(100)
- Social Progress Index (82)
- Inclusive Growth Index (45)
- Human Capital Index (98)
- Global Social Mobility Index
(73)
- Maternal well-being index
(125)
- Child Rights Index (72)
- Global Happiness Index (89)
- Quality of Death Index (52)
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APPENDIX 2: HEALTH SYSTEM AND CARE OFFERS IN MOROCCO
Health system
Public Sector
Includes the network of primary health care establishments; the network of
hospitals; the integrated emergency medical care network; the network of medico- social establishments; the public health institutes and centers
Semipublic
sector
Includes the clinics of the National Social Security Fund, the medical services
provided by some administrations, the health establishments and consultations
provided by some public establishments and the health structures of some private
companies and foreign institutions
Private sector
Includes: a) profit-making structures (medical practices, dental practices, clinics,
etc.); b) Non-profit structures (mutual insurance companies, Moroccan Red
Crescent establishments, leagues and foundations)
Military
sector
Brings together all the health structures and services of the Royal Armed Forces
Source: Ministry of Health, 2017.
Health Map - Health Care Supply Situation (2020)
Geographical
distribution
of health care
Health
Regions :
12
Health
Provinces:
82
Urban
Health
Districts:
269
Rural Health
Districts:
717
Public
Infrastructure
Primary
Health
Care
establishm
ents
Urban
Health
Centers :
847
Rural
Health
Centers :
1,279
Hospital
establishm
ents
Hospitals :
152
(25,440
beds)
Psychiatric
hospitals :
10 (1,486
beds)
Haemodialy
siscenters :
120 (2,376
Dialysis
machines)
Private Sector
Health
establishm
ents
Clinics: 375
(10,562
beds)
Medical
consulting
rooms:
10,125
Radiology
office: 283
Laboratory:
582
Pharmacies
:
9,189
Source: Ministry of Health
(http://cartesanitaire.sante.gov.ma/dashboard/pages2/index_19.html).
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URL: http://dx.doi.org/10.14738/assrj.910.13336
APPENDIX 3: PLANS AND PROGRAMS ADOPTED FROM 2003 ONWARDS
Plans
&
programs
Scope & aims Reference link
Health
Action
Plan 2003-
2007
Reform the Moroccan health system
(basic medical coverage, compulsory
health insurance (AMO), Medical
Insurance Scheme for the Economically
Deprived (RAMED), hospital reform,
and regionalization)
https://applications.emro.who.int/dsaf/libcat
/EMRDOC_6_FR.pdf
National
Initiative
for Human
Developm
ent (2005)
Contribute to reducing maternal and
infant mortality, improving the health
of women in rural areas, and promoting
childbirth in a supervised environment
http://www.indh.ma/generations-montantes/
National
Plan of
Action for
Children
(2006-
2015)
Entitled "Morocco Fit for its Children",
in partnership with UNICEF & UNFPA, it
promotes the rights of Moroccan
children
https://evaw-global-database.unwomen.org/-
/media/files/un%20women/vaw/full%20text
/africa/pane%20-
%202006%20to%202015%20-
%20french.pdf?vs=144
National
Child
Health
Action
Plan
(2006-
2015)
Correct certain anomalies: poor overall
management of the sick child; an
absence of certain services (vaccination
against hemophilia influenza B,
screening for certain disabilities,
psycho-affective and social
development, etc.); low attention to the
specific needs of children aged 5-15
years (20% of the population); and a
low level of prenatal care and advice
(prenatal consultation, supervised
childbirth, practice of caesarean
section, breastfeeding, fight against
micronutrient deficiencies
https://planipolis.iiep.unesco.org/en/2006/pl
an-daction-national-pour-lenfance-2006-
2015-maroc-digne-de-ses-enfants-4579
Health
Action
Plan
(2008-
2012)
As part of a national plan for reducing
maternal and neonatal mortality (a
millennium objective), a component
related to child and adolescent mental
health was included
https://www.who.int/goe/policies/morocco_p
lan_2008_2012.pdf?ua=1
NAJAH- Emergenc
y Plan
(2009-
2012)
Improve the health of children and
young people (medical cells in each
regional delegation, medical care
supplies in each primary school,
medical consultations and care for
pupils, standards of safety and hygiene,
anti-smoking and anti-drug use, etc.)
https://planipolis.iiep.unesco.org/sites/defaul
t/files/ressources/morocco_programme_urge
nce_najah_rapport_synthese.pdf
National
School and
University
Several objectives were addressed,
including reducing the prevalence of
risk behaviors among young people
http://santejeunes.ma/strategie-nationale-de- la-sante-scolaire-et-universitaire-2011/
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Health
Strategy
(2011)
(tobacco, drugs, etc. ), increasing the
use of health services by young people,
reducing dental caries among 12-year- olds and correcting the vision of all
children identified as visually impaired
National
Youth
Health
Promotion
Strategy
(2011)
Help reduce the risk of young people
becoming addicted to various harmful
substances (alcohol, tobacco, drugs,
etc.), to encourage them to engage in
sports instead, and to equip them with
good health knowledge (sexual and
reproductive health)
http://santejeunes.ma/strategie-nationale-de- promotion-de-la-sante-des-jeunes-2011/
National
Nutrition
Strategy
(2011-
2019)
strengthening the skills of health
specialists in child nutrition,
encouraging breastfeeding by
reactivating the "Baby Friendly
Hospitals" initiative, and providing
health facilities with equipment to
assess and monitor the nutritional
status of newborns and young children
https://www.sante.gov.ma/Publications/Guid
es- Manuels/Documents/Couv%20Strat%C3%A9
die%20de%20Nutrition.pdf
Health
Sector
Strategy
(2012-
2016)
The adoption and implementation of a
national child health policy". In
addition, the plan aims to be
comprehensive by addressing school
and university health as well as the
health of populations with special
needs (disabled people, elderly people,
abused children and women, etc.)
https://www.sante.gov.ma/Docs/Documents/
secteur%20sant%C3%A9.pdf
Integrated
National
Youth
Strategy
(2015-
2030)
Ensure coherence among government
actions towards youth while
complementing and strengthening
sectoral strategies and plans
http://www.mjs.gov.ma/sites/default/files/st
rategie-morocco.pdf
Health
Sector
Strategy
(2017-
2021)
Improve child and youth health and
populations with special needs through
several actions (development of norms
and standards; institutional, regulatory
and organizational support; social
mobilization; supply of medicines,
consumables and equipment;
development of human capital skills,
strengthening of operational research,
etc.)
http://lof.finances.gov.ma/sites/default/files/
budget/files/pdp_plf2017_ms_version_francais
e_vf.pdf
National
Strategic
Plan for
the
Promotion
of Mental
Health of
Reduce the prevalence of mental
disorders and the suffering associated
with impairments and disabilities, to
ensure early detection of mental health
problems and addictive behaviors, and
to guarantee equitable access to
integrated, quality and continuous
https://www.psychiatrieagadir.org/formation
/documentation/plan-strategique-de- promotion-de-la-sante-mentale-des-enfants- des-adolescents-et-des-jeunes/
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URL: http://dx.doi.org/10.14738/assrj.910.13336
Children,
Adolescen
ts and
Youth
(2018)
medico-social services
Health
Plan 2025
Several actions of it affect directly child
health (enhancing the national child
health policy, strengthening the
pregnancy and childbirth surveillance
program, establishing regional centers
of excellence for maternal and child
health, and upgrading supervised
childbirth facilities, particularly in rural
areas; revitalization of the national
system for monitoring and evaluating
maternal and child health;
consolidation of the National
Immunization Program (NIP);
introduction of the HPV vaccine for
girls aged 9 to 13; etc.)
https://fr.scribd.com/document/444512249/
Maroc-Plan-Sante-2025
Integrated
National
Child
Health
Policy to
2030
Reducing morbidity and mortality
among children, ensuring their
equitable access to quality health
services, influencing the social
determinants of children's health
(factors of inequality), strengthening
and implementing integrated and
multisectoral territorial systems of
action for children, and ensuring
children have access to and
participation in making decisions about
their health and well-being
https://www.sante.gov.ma/Publications/Guid
es- Manuels/Documents/2020/Politique%20nati
onale%20int%C3%A9gr%C3%A9e%20de%20
la%20sant%C3%A9%20de%20l'enfant.pdf