By Fahdi Dkhimi, Research Assistant at Institute of Tropical Medicine, Antwerp, Belgium

As highlighted by Gwatkin recently in the Lancet, the beginning of the third millennium has been marked by renewed interest in equity and poverty, usually embedded in a more broadly desired political objective: achieving Universal Health Coverage (UHC).

UHC, “the single most powerful concept that public health has to offer” according to Margaret Chan, has greatly gained momentum in Africa over the past 18 months – noticeably via a number of international and regional encounters – leading many African governments to show their commitment toward this policy goal.

Behind this goal lies the key issue of access to care for the poorest. The issue has been regularly debated ever since the introduction of user fees in most of the facilities of the developing world; it is only in recent years though that some African countries have embarked on a major policy move, aiming at extending the scope of their pro-poor interventions in the health sector. Such a process finds its practical translation into a symbolic shift from the well-known but often ineffective certificate of “indigence” to more complex financing mechanisms targeting the poorest. What can we learn from these experiences? Have these new mechanisms been more effective in protecting the poorest? Or shall we echo Valery Ridde et al.’s words of disappointment, expressed last year on the situation in West Africa: “30 years afterAlma-Ata and 20 years after the Bamako Initiative, the worst-off still do not have access to care”?

These questions were at the center of intensive discussions carried out last week during the second workshop organized by the Community of Practice – Financial access to health services in Africa. This event took place in the beautiful city of Marrakesh, Morocco – the “Ochre City” – under the patronage of the Moroccan Minister of Health. More than 90 participants from 11 different countries participated in the event to share experiences, learn from each other, debate and discuss how to reach the poorest. As Lara Brearley already mentioned  elsewhere, participants were encouraged to be honest and frank about prevailing challenges, probed by a few academics, members of parliaments and technical experts which resulted in very rich debate.

But this workshop was not only about discussions. It turned very practical thanks to the commitment of the Moroccan Ministry of Health, and its willingness to cast light on its national effort to develop a comprehensive strategy to reach out to people identified as poor or vulnerable. After the user fee removal at the primary care level, the Moroccan Ministry of Health has taken a step forward this year to meet this objective, bringing a medical assistance scheme to the whole country:  RAMED, or the Medical Assistance Regime for the Economically Disadvantaged. RAMED aims at covering secondary and tertiary care fees for about 8.5 million of citizens, i.e. 28% of the total official population, entitled to this targeted subsidy model.

The field visits organized during the workshop opened the floor to fascinating debates among peer countries grouped by language affinities. We had the opportunity to be ‘rapporteurs’ for the group that constituted of the Ghanaian, Nigerian and Kenyan delegations. A true opportunity, really, as gathering African Anglophones’ views on the Moroccan strategy is definitely one of the plusses brought by the CoP model and this despite the sometimes huge differences between settings.

If the participants acknowledged that it was too early to judge, both because of the limited observational field (only 3 sites visited) and the novelty of the reform – the scaling up of the RAMED scheme being implemented only for a few months – they however expressed a few concerns that may lead to implementation gaps in the medium term. Two of these concerns are worth to be shared, we think, especially with those involved in the formulation and/or the implementation of pro-poor strategies in their respective countries.

First, observations made in the field showed that only few people have, so far, struggled through the rather ‘bureaucratic’ process required to get the RAMED card. On this aspect, participants questioned the relevance of a passive identification model, which seems to impede access to RAMED benefits for the most destitute. Participants stressed the inherent risk of self-declarative procedures to generate exclusion, especially when these procedures are handled by the local representation of the Ministry of Home Affairs, whom those most in need are usually reluctant to approach, at least in their respective countries.

Secondly, if the participants praised Morocco for its national commitment, they also discussed the lack of involvement of some of the key stakeholders in their view, for e.g. the Ministry of Social Affairs, when it comes to improving access for the poorest., They stressed the key roles of these actors to keep the momentum high on the issue of access for the poorest. Such long term commitment is indeed critical to secure RAMED funding in the long run, especially in a period of financial crisis and budgetary arbitrations. Worries were expressed on this matter, especially after direct observation of nurses on strike for better remuneration in one of the visited facilities.

In the case of Morocco, the Arab spring has surely accelerated a political process that was underway. However, was the system ready for such a fast move? Other issues could also be pointed out besides the never-ending key discussions on funding and identification process, e.g. integration with other major national insurance schemes, or under-staffing issues. It is too early to judge, but the RAMED programme is definitely worth a closer look as one of the few examples in Africa and the Arab world of large-scale pro-poor strategies. The Moroccan path toward UHC will be contingent – i.e. built on the outcomes of politics and contestation – and incremental. Challenges will definitely occur, but at least something is happening in Morocco. Given that it’s such a key issue, we hope other countries will follow.

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