Social inequalities and health inequity in Morocco
© Boutayeb; licensee BioMed Central Ltd. 2006
Received: 20 July 2005
Accepted: 07 March 2006
Published: 07 March 2006
According to the last census, Morocco has a population approaching 30 million people. The country has made good progress in the control of preventable childhood diseases but social inequalities and health inequities remain major problems for the third millennium. Despite the progress achieved during the last decade, the country still ranks at the 125th place according to the Human Development Index. This unpleasant position is mainly explained by illiteracy, education and health indicators.
Our study was based mainly on annual reports and regular publications released by the United Nations (UN), United Nations Development Programme (UNDP), World Health Organisation (WHO), The Moroccan Health Ministry and related papers published in international journals.
Results and discussion
As indicated by the last Arab Human Development Reports (AHDR 2002, AHDR 2003, AHDR 2004) and implicitly confirmed by the "National Initiative for Human Development" (NIHD) launched in May 2005 by the King of Morocco, many districts and shanty towns, urban or peri-urban, and a multitude of rural communes live in situations characterized by difficult access to basic social services of which education and health are examples.
Recent evidence showed that improved health is more than a consequence of development. It is a central input into economic and social development and poverty reduction. Serious initiatives for human development should consider the reduction of social inequalities and health inequities as a first priority. Otherwise, the eventual development achieved cannot be sustained.
According to the last census, Morocco has a population approaching 30 million people, experiencing a transition on different levels. In 2005, 55% of the population is living in urban areas, compared to 43% in 1982 and 29% in 1960. The Moroccan population is young, with 38% under the age of 14 years, and life expectancy at birth has increased from 65 in 1980 to 68.5 in 2004. The country has made good progress in the control of preventable childhood diseases but social inequalities and health inequities remain the major problems for the third millennium.
Despite the diverse resources (agriculture, phosphates, fishing, potentialities for tourism, etc...) and the progress achieved during the last decade, the country still ranks 125th according to the Human Development Index (HDI) (UNDP, 2004). This unpleasant position is mainly explained by low income, high adult illiteracy, lack of generalized education, and health indicators. The reports released by the UNDP and essentially the last three Arab Human Development Reports (AHDR2002-2004) [2–4] indicate that little improvement has been achieved during the last decade. The Moroccan authorities have been trying to find excuses rather than dealing with the real causes of such insufficiencies in human development. The "National Initiative for Human Development" (NIHD), launched in May 2005 by the King of Morocco, has at last, admitted that many districts and shanty towns, urban or peri-urban, and a multitude of rural communes live in uncomfortable situations characterized by difficult access to basic social services such as education and health.
The Moroccan system of health care production is organized into three sectors:
• The public health care sector: This is the largest sector present throughout the country, providing 85% of the country's hospital beds and representing the main employer of health professionals in Morocco. This sector is supposed to deal particularly with the needs of poor and rural populations who are unable to afford the service offered by the private sector.
• The private health care sector: This is a profit-making sector which is mainly present in cities. It is principally attended by people with sufficient income or those who have health insurance.
• The non-profit health sector: This sector is present exclusively in big cities and run mainly by the National Security Fund (CNSS). Its care is devoted to the 16% of the population covered by health insurance.
During the last decades, an important literature was devoted the differences and connections existing between social justice and health equity [5–8]. More and more publications are dealing with health of the poor , health equity and health as a cornerstone of sustainable development . According to the authors of Dying for Growth , economic growth, far from being a panacea, often accelerates the suffering of poor and marginalized people. Building on this, the present paper deals with social inequalities and health inequity in the special case of Morocco.
Data from different sources were used in order to study the inequalities in terms of income, consumption, education and health opportunities. In our search, we used MEDLINE data base (via the Pub Med web site) for related publications, the reports released by The World Health Organisation (WHO) the United Nations Development Programme (UNDP) and regular publication of the Moroccan health authorities.
Results and discussion
Morocco is characterized by contrasting phenomena and huge inequalities at different levels. For ease of clarity, we will concentrate on disparities (milieu, sex, region) according to income, education and health.
Stagnant growth and income inequality
Share of income & consumption: Ratio of the richest 10% to the poorest 10% [4, 19]
Adult literacy rate (% ages ≥ 15) and combined gross enrolment ratio 
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 , 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).
Literacy rate 1998–1999: Milieu, sex and class of income 
Health indicators: Morocco compared to Arab countries 
Life Expectancy at birth
Lost healthy years
Maternal Mortality Ratio
per 100 000
Infant Mortality Rates
per 1000 live births
Per 100 000 people
Geographical disparities 
Inhabitants per physician
Inhabitants per dentist
Gender inequalities in health, income and education 
Life expectancy at birth (2002) in years
Expectation of lost healthy years at birth (2002) in years
Estimated earned income (2002) (PPP US$)
Share of non-agricultural wage employment 2001 (%)
Combined gross enrolment ratio for primary, secondary and tertiary level schools 2001/02 (%)
Adult literacy rate (2002) ages 15 and above (%)
Regional inequalities [4, 12]
% of population below national poverty line 1992–2000
% of population using improved drinking water source 2000
% of population using adequate sanitation facilities 2000
% of population unable to afford essential medical care in 1998–99
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 . 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 .
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.
Morocco is facing the growing impact of communicable and non communicable diseases. In the meantime, the burden of illiteracy and the slow economic growth, conjugated to huge inequalities and sharp inequities, maintain the Human Development Index of the country at a level contrasting with its human and natural resources. The "National Initiative for Human Development" launched by the King of Morocco is based on the fact that broad fringes of the population live in precarious conditions and sometimes in a situation of poverty and marginalization contrasting with the image of Morocco. Considering the delay in human development accumulated by the country during the last decades, political initiatives are unlikely to succeed in the absence of pragmatic and efficient measures that tackle seriously the problems of regional disparities, social inequalities and health inequities.
This paper is dedicated to my wife Hayat and our children Wiam, Hanae and Aymane for their continuous and comprehensive family support.
The autho(r) declares that he has no competing interest.
This work has been supported by the Global Research Programme of University Mohamed Ier.
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