Source: Death and the Miser ↪
There exists a particular form of policy failure that transcends simple incompetence or resource scarcity. It occurs when a reform's very success becomes the mechanism of its fundamental betrayal. Morocco's quest for universal healthcare coverage presents such a case: a systematic inversion where the instruments designed to guarantee a public good have become the primary catalysts for its commodification.
This is not merely a story of privatization, a term that suggests a deliberate transfer of assets from public to private hands. What unfolds in Morocco is more subtle and perhaps more consequential: the construction of a dual architecture where the state's social mandate becomes the financial foundation for a parallel, market-based system. The mechanism is elegant in its perversity. The government extends coverage to millions while simultaneously ensuring that this coverage flows predominantly toward private providers. The public promise becomes the private sector's business model.
To understand this inversion requires examining the deliberate production of institutional failure. The Moroccan public health system's decline was not an accident of history but the predictable outcome of specific policy choices sustained over decades. With health investment hovering around 6% of governement spending ↪, the state created conditions where out-of-pocket payments would inevitably constitute over half of all health expenditures. This was not oversight but architecture.
The geographic distribution of this decay follows a precise logic. While the state maintained the formal infrastructure of universal access (160 hospitals, 3,000 primary care facilities), it concentrated functional capacity along major urban centers. This created what we might call "performed universality": the appearance of nationwide coverage masking the reality of systematic exclusion. Rural populations encounter not the absence of healthcare but its simulation: facilities that exist on paper, in government reports, in the national imagination, but not in operational reality.
The human resources crisis represents the most sophisticated element of this architecture. The annual exodus of 600-700 doctors ↪, which constitutes 30% of each graduating class, is typically framed as brain drain, suggesting an unfortunate but unintended consequence. Yet when examined structurally, this hemorrhage appears almost engineered. The state trains medical professionals to global standards, then places them in conditions that make departure not just attractive but necessary for professional dignity. The system produces its own abandonment.
The passage of Law 131-13 ↪ in 2015 marked a critical shift from implicit to explicit policy. By permitting non-medical investors to own healthcare facilities, the state did more than enable privatization. It redefined healthcare's ontological status. Medical care transformed from a professional practice embedded in social obligation to an asset class subject to financial optimization.
This "financialization" represents a particular form of abstraction. Healthcare becomes disconnected from its material reality (the suffering body, the healing relationship) and reconstituted as a series of revenue streams, market opportunities, and investment vehicles. The Akdital Group's trajectory exemplifies this transformation. Founded in 2011 with a single clinic, it has evolved into an empire of 38 facilities with 4100 beds, its expansion fueled by private equity, a record IPO, and a business model that separates real estate assets from hospital operations, a strategy borrowed from industries where the product is fundamentally commercial.
Akdital's self-presentation is revealing. It frames its expansion not as business growth but as patriotic duty, positioning itself as essential to realizing the royal vision of social protection. This rhetorical move is crucial: private capital does not oppose the public good but claims to be its most effective servant. The market presents itself as the solution to state failure, a failure the state has systematically produced.
The 2020 announcement of universal health coverage through the generalization of AMO (Assurance Maladie Obligatoire) represents the apotheosis of this structural inversion. The reform's stated objective of enrolling 22 million citizens was achieved through a mechanism that would fundamentally redirect the flow of public resources.
The critical innovation was subtle: allowing AMO-Tadamon beneficiaries to access both public and private facilities. This single policy change transformed millions of poor citizens from users of public services into consumers in a healthcare market. The state, unable to provide adequate services directly, instead provided purchasing power. It abdicated its role as provider while maintaining its role as payer.
The mathematics of this arrangement are stark. While the public sector provides 83% of all healthcare services, it receives only 42% of total health spending. The private sector, handling just 17% of care, captures 58% of expenditures. ↪ This is not market distortion but market design: a system where public funds flow according to a logic that privileges commercial efficiency over social need.
The state has become, in effect, the primary venture capitalist for private healthcare. Through mandatory insurance contributions and subsidies for the poor, it guarantees both demand and payment for private providers. Risk is socialized while profit is privatized, a familiar neoliberal formula executed with particular sophistication.
This system produces a specific form of citizen subjectivity. The individual confronting illness faces not a right to be claimed but a market to be navigated. Even with insurance, the gap between coverage and cost, with out-of-pocket expenses consuming 43% of real costs ↪ transforms healthcare from entitlement to commodity. The 36% of insured citizens who forgo necessary treatment due to cost ↪ are not failures of the system but its logical products.
The AMO-Tadamon scheme's eligibility mechanisms reveal the deeper logic at work. The Unified Social Register assigns families a "score" that determines their access to subsidized coverage. Healthcare becomes not a universal right but a privilege distributed according to algorithmic assessments of poverty. Those who fall marginally above arbitrary thresholds are excluded entirely, too poor to afford private care, too "wealthy" for public assistance.
This creates what we might call "performed coverage", the possession of an insurance card that provides not access to care but access to the possibility of care, contingent on one's ability to bridge the financial gap. For 3.5 million people with "closed rights," coverage exists purely as administrative fiction.
The Moroccan state has not retreated from healthcare but transformed its mode of governance. It has shifted from direct provision to market regulation, from service delivery to financial administration. The creation of the High Authority of Health (HAS) represents this new governmental logic: the state as referee in a game whose rules it has written to ensure particular outcomes.
This raises a fundamental question about state capacity. Can a government effectively regulate a private sector it has made structurally indispensable? The state's dependence on private capital to fulfill its constitutional obligations creates a form of regulatory capture that precedes any actual lobbying or corruption. The capture is built into the system's architecture.
The medical unions' resistance and civil society's protests represent more than sectoral grievances. They constitute a form of epistemic resistance, a refusal to accept the redefinition of healthcare from social right to market transaction. Yet this resistance confronts not merely policy choices but an entire apparatus of knowledge production that frames market delivery as modernization, efficiency as justice, and privatization as democratization.
Morocco's experience is not isolated but exemplary. Tunisia and Egypt are implementing similar reforms, creating state-guaranteed markets for private healthcare providers. This suggests a regional (perhaps global) shift in how states conceptualize their social obligations. The welfare state does not disappear but mutates into what we might call the "market-making state", one that creates and sustains markets rather than directly providing services.
This transformation is presented as pragmatic adaptation to fiscal constraints and efficiency demands. Yet it represents a fundamental reconceptualization of the social contract. The state no longer promises to provide for its citizens but to provide them with access to markets. The citizen is reconstituted as consumer, rights as purchasing power, and solidarity as risk pooling.
Morocco's healthcare system exists in a state of permanent transition. Each reform promises to address the failures of the previous one, yet each deepens the fundamental contradiction: a public system starved of resources alongside a private system gorged on public funds. This is not a transitional phase toward some future equilibrium but the system's steady state.
The question is not whether Morocco will have universal healthcare coverage, it already does, formally. The question is what kind of universality this represents. Is it genuine access to care as a social right, or universal conscription into a healthcare market where one's suffering becomes another's profit opportunity?
The future of Moroccan healthcare will be determined not by technical adjustments or incremental reforms but by a fundamental choice about the nature of social solidarity. The current trajectory suggests this choice has already been made, encoded in law, institutionalized in practice, and internalized in consciousness. The transformation of healthcare from right to commodity may be approaching a point of irreversibility, where the market logic becomes so embedded in the system's operation that alternatives become not just politically difficult but conceptually unthinkable.
The health of 37 million Moroccans hangs not in the balance but in the market, subject to its fluctuations, its failures, and its fundamental indifference to human suffering that cannot be monetized. This is the price of health in contemporary Morocco: not what it costs, but what it has cost us to reimagine healing as transaction, care as commodity, and solidarity as consumer choice.