Morocco: a primary Mohamed Berraho

health care case study Ibtissam El Harch

Soumaya Benmaamar

in the context of the Moncef Maiouak

Hafid Hachri

COVID-19 pandemic
 Morocco: a primary health
care case study in the context
of the COVID-19 pandemic

Mohamed Berraho Moncef Maiouak

Ibtissam El Harch Hafid Hachri

Soumaya Benmaamar
Morocco: a primary health care case study in the context of the COVID-19 pandemic/
Mohamed Berraho, Ibtissam El Harch, Soumaya Benmaamar, Moncef Maiouak,
Hafid Hachri

ISBN 978-92-4-007295-4 (electronic version)

ISBN 978-92-4-007296-1 (print version)

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 Morocco: a primary health care case study
in the context of the COVID-19 pandemic

Contents

Acknowledgementsiv

Executive summary v

Introduction1

Methods1

National context 2

How primary care and essential public health functions

are responding to COVID-19 4

How multisectoral policy and action are responding to COVID-19 8

How communities are responding to COVID-19 10

Conclusion and lessons learned 11

References12

iii
 Ackowledgements

Acknowledgements

The primary health care (PHC) case studies in the Eastern Mediterranean Region
were commissioned and overseen by the Alliance for Health Policy and Systems
Research, a hosted partnership based at World Health Organization (WHO)
headquarters, and the WHO Regional Office for the Eastern Mediterranean
(EMRO). This case study was authored by: Mohamed Berraho, Ibtissam El Harch,
Soumaya Benmaamar and Moncef Maiouak from the Laboratory of
Epidemiology, Clinical Research and Community Health, Faculty of Medicine
and Pharmacy, Sidi Mohamed Ben Abdellah University, Fez, Morocco; and Hafid
Hachri from the WHO Country Office for Morocco. WHO EMRO, the WHO Country
Office for Morocco, and a team of independent experts provided critical review
and input. Special thanks go to Shehla Zaidi and Fadi El-Jardali for their helpful
reviews, and Awad Mataria, Hassan Salah, Hagar Azab, Faraz Khalid, Robert
Marten, Jeffrey Knezovich, Sonam Yangchen, Alexandra Edelman, Yasmine
Yahoum, Ragaa Hassan Abdelwahed, Joanna Fottrell and David Lloyd for their
support in the development of this publication. Thanks also go to the Directorate
of Population, the Directorate of Epidemiology and Disease Control, the Regional
Directorate of Health Fez-Meknes and the University Hospital Hassan II Fez for
their help in the development of this work.

iv
 Morocco: a primary health care case study
in the context of the COVID-19 pandemic

Executive Summary

Primary health care (PHC) plays a critical role in prevention, preparedness and
response and in ensuring the continuity of access to essential health services
during health emergencies.

This case study examines PHC in Morocco in the context of the COVID-19
pandemic between early 2020 and August 2022, across the three PHC
components codified in the 2018 Astana Declaration (primary care,
multisectoral collaboration and community engagement) (1). A case study
approach was used to combine documentation review and stakeholder
consultations with 13 individuals who were selected to provide insights across
a range of roles within the health system.

A National Plan of Surveillance and Response to Coronavirus 2019-nCoV

Infection (2) was developed in January 2020 with the purpose of organizing and
standardizing actions at the national and regional level in health care and other
sectors. Resources and efforts were deployed at an early stage in the
pandemic to increase surge capacity for diagnosing and managing confirmed
cases. The PHC department and its large network of PHC centres were
integrated in the national preparedness and response plans. The government
capitalized on this network to supplement and augment the national response
to COVID-19, with the aim of reducing community transmission, raising
awareness, delivering health promotion and community education, reinforcing
the importance of screening and early detection, and sustaining PHC essential
services while also prioritizing staff safety.

Multisectoral collaboration was also strengthened to address the pandemic’s

health, social and economic consequences. An emphasis on primary care was
included in the national and territorial governance of the crisis, which strengthened
linkages and referrals across different levels of care. The authorities also took
measures to counteract the economic impacts of the pandemic through the
creation of a special fund for medicines, materials and vaccines.

The involvement of PHC services led to reductions in other services and

programmes, particularly in the context of insufficient human resources.
However, the commitment of health professionals and the population made
it possible to minimize the impact of the pandemic on other health programmes.
Overall, Morocco’s response involved the mobilization of resources and
innovative solutions to manage spread and impact and to ensure the continuity
of health services.

v
 Morocco: a primary health care case study
in the context of the COVID-19 pandemic

Introduction

On 11 March 2020, the World Health Organization (WHO) first characterized the
COVID-19 outbreak as a pandemic (3–6). The pandemic is a defining global and
national political priority, with profound implications for nearly every aspect of
health (7, 8).

The National Plan of Surveillance and Response to Coronavirus 2019-nCoV

Infection in Morocco aimed to slow and stop transmission, and to prevent
outbreaks; to provide optimized care for all patients, especially those who were
seriously ill; and to minimize the impact of the pandemic on health systems,
social services and economic activity (2). Unprecedented response strategies
were needed such as mass surveillance, and the creation of a sophisticated
network of diagnostics and medical facilities for the immediate detection and
treatment of the disease (9). Also, at the start of the pandemic in 2020, general
and individual transmission reduction measures were established to help delay
virus spread (10, 11).

In public health emergencies, PHC plays a critical role in preparedness and

response and in ensuring continuity of access to essential health services (12).
PHC also has a role to play in improving equity, with the involvement of
communities as partners (13). The Declaration of Astana on PHC acknowledges
that a PHC approach empowers people and communities, addresses the
determinants of health in a multisectoral way, and ensures strong primary care
as the core of integrated service delivery with essential public health functions (1).
In 2020 and 2021, many countries’ health systems prioritized the supply of
hospital care to manage severe and critical cases of COVID-19 (13). In Morocco,
the challenges were exacerbated by a severe lack of human resources for health
(14) and weak health financing (15, 16).

Globally, primary care services were not sufficiently supported during the
pandemic to conduct surveillance and to respond to or undertake community-
based care with appropriate infection prevention and control and effective
referral mechanisms (17). Gaps in PHC implementation weakened the ability of
countries to detect and respond and to maintain essential health services (18).

This case study examines the role of PHC in the COVID-19 pandemic response
in Morocco between early 2020 and August 2022, across the three components
of the Astana framework.

Methods

The WHO Operational Framework for PHC was used in data collection and
analysis (12). A case study approach was employed, with data collected in two
phases. First, data were collected on the different components of the Framework
using a comprehensive documentation review. This step involved a review of
policy documents, legislative acts, guidelines, strategic plans and programmes,

1
 Introduction and national context

and reports and research papers. PubMed and Google Scholar were used to
search for published research papers and reports using the following search
strategy: (novel coronavirus OR COVID-19 OR SARS-COV-2) AND (primary care OR
primary healthcare OR community OR family medicine OR outpatient OR
ambulatory) AND (Morocco OR Moroccan). The websites of governmental bodies
(including ministries and public agencies for national-level reports, legislation,
plans and documents) and of key intergovernmental organizations (e.g., the
United Nations Development Programme (UNDP), WHO and World Bank) were
searched for relevant studies. News articles on the pandemic response were
also identified and included.

Following this documentation review, stakeholder consultations were conducted

to gain additional insights on all three PHC components and validate key findings.
A question guide was developed with lines of enquiry corresponding to the
different PHC components. Thirteen stakeholders across a range of roles within
the health system contributed their insights. Stakeholders included national
officials from the Ministry of Health (MoH) (MoH Division and services of the
Population Directorate) and regional officials in the Fez-Meknes region, as well as
doctors working in PHC centres, taking into account the place of residence (rural
and urban). Data were collated, analysed and categorized according to the three
PHC components.

National context

Morocco is a lower-middle-income country with a population of around 37 million

people, of which nearly two thirds live in urban areas. The population grew at an
average rate of 1.1% annually between 2010 and 2020 (19). The total fertility rate
was 2.3 children per woman of childbearing age between 2015 and 2017, and life
expectancy at birth was 76.4 years in 2019 (19–21). In 2020, it was estimated that
around 28.2% of the population was under 15 years of age (19).

The 2011 Constitution established a democratic and parliamentary government

system with a monarchy and a largely centralized administrative system (22).

The health system is organized into five areas: a hierarchical and

compartmentalized public health system, a rapidly expanding private sector, a
semi-public sector, mutual benefit institutions and traditional medicine. The MoH
provides the vast majority of curative services and almost all preventive services,
while public–private partnerships are currently underdeveloped (15, 22–24).

In 2019, Morocco had 159 hospitals and 2888 urban and rural PHC establishments.
There were 12 034 doctors of all specialties and a workforce of 31 657 paramedics,
compared to 13 545 doctors practising in the private sector, including 8355
specialists. In the private sector, there were 359 clinics, 9671 medical consultation
offices, 3614 dental surgery offices and 8997 pharmacies (20).

There is a severe shortage of health professionals and great disparities in

distribution – between regions and within regions, and between urban and rural

2
 Morocco: a primary health care case study
in the context of the COVID-19 pandemic

Table 1. Overview of key indicators for the health sector

in Morocco, 2020

Indicators Results

Demographic and socioeconomic determinants

Total population 36 667 977

Urban population (%) 60.4

Sex ratio: male/female 1.006

Average annual population growth rate (%) 1.1

Fertility rate (per woman of childbearing age) 2.3

Life expectancy at birth 76.4

Infant mortality rate (deaths per 1000 live births) 18

Under-5 mortality rate (deaths per 1000 live births) 4.23

Maternal mortality rate (deaths per 100 000 live births) 72.6

% active population (aged 15–60 years) 62.4

Gross domestic product (GDP) US$ 128.6 billion

GDP/capita US$ 3442.4

Employment rate (% population) 39

Unemployment rate (% population) 12.2

% uninsured population 45.4

Social determinants of health

Literacy rate (%) 32

Poverty rate (% population living in poverty) 4.8

Source: Data derived from WHO, MoH, Haut Commissariat au Plan (HCP) Maroc and World Bank (15, 19–23)

areas. The ratio of health professionals per 10 000 inhabitants is barely 6.2,
which is below the WHO recommended threshold of 23 health professionals per
10 000 inhabitants. The number of paramedics trained in childbirth care is less
than 2.28 per 1000 population (16, 22–26).

Total health expenditure for 2018 reached about 60.9 billion dirhams
(approximately US$ 5.9 billion), compared to 52 billion dirhams (approximately
US$ 5 billion) in 2013. This represents an overall increase of 17.1% and an average
annual increase of 3.2% (16, 22, 25, 27). Households remain the main financiers of
health, contributing 45.6% of direct expenditure on health services with the state

3
 Introduction and national context

contributing 22.3% (28). In 2018, the contribution of international support to health

financing represented 0.2% of direct health service expenditure (28).

Only 54.6% of the population has basic health insurance coverage. The various
care services provided at PHC facilities are offered to the population free of
charge. The National Health Insurance Agency (ANAM) is a public institution
of an administrative nature, endowed with legal authority and financial
autonomy. Its mission is to ensure the technical supervision of the basic
compulsory health insurance scheme and the implementation of tools to
regulate the system in compliance with related legislative and regulatory
provisions.

The MoH is responsible for developing and implementing the government’s

population health policy, which includes the national drug and pharmaceutical
policy at the technical and regulatory levels (25). The 2011 Constitution made
access to health care and social protection a basic right (23, 29).

Historically, the health system has gone through several phases of development
(25). An ongoing major reform at the time of writing was the creation of a High
Authority for Integrated Health Regulation (HARIS) and the generalization of
national health insurance (29). At the time of writing, the country was
implementing new health system reforms, articulated around four pillars: good
governance, the development of human resources, upgrading health care
services and digitization.

As of 7 August 2022, Morocco recorded 1 262 622 confirmed cases of COVID-19

and 16 257 related deaths (30). The number of adults fully immunized against
COVID-19 was 23 469 735 (63.6% of the adult population) in August 2022 (31).

How primary care and essential public health

functions are responding to COVID-19

The National Plan of Surveillance and Response to Coronavirus 2019-nCoV

Infection (2) was created in January 2020 with the purpose of organizing and
standardizing actions at the national and regional level in health care and other
sectors. This Plan was developed by the MoH based on its assessments of risk
and of the available capacity. The aim of the Plan was to prevent the
introduction of COVID-19; detect cases early and contain virus spread; organize
an appropriate national response from the health system; and strengthen
measures for infection prevention and control. This approach emphasized
coordination through the use of technology (for example, WhatsApp to speed
up the dissemination of information).

The National Plan was followed by a general mobilization of the country’s health
system. Priority was given to strengthening health care services, including the
laboratory network. Indeed, the diagnostic capacities of laboratories were
rapidly strengthened, notably by using existing resources and by creating new

4
 Morocco: a primary health care case study
in the context of the COVID-19 pandemic

capacities (e.g., through the involvement of university specialties in molecular

biology). Diplomatic action and excellent relations between Morocco and other
countries facilitated the availability of medicines, medical devices and other
equipment.

Government departments and health professionals quickly mobilized with other

sectors to respond to the COVID-19 pandemic in early 2020. An Interministerial
Vigilance Committee piloted an action plan. The MoH deployed actions to
monitor the epidemiological situation in real time, and established a Technical
and Scientific Advisory Committee to inform adjustments to the response.
The main mission of this Committee was to define a protocol for the
management of patients with COVID-19, to adapt the organization of the care
system in response to epidemiological data and to provide recommendations
on information dissemination to the public.

On 15 March 2020, Morocco suspended all international passenger flights. In

addition, a state of health emergency was declared on 24 March. On the same
day, Decree-Law 2.20.292 was introduced, which serves as a legal framework
to respond to COVID-19 (32). Decree No. 2.20.293 was also introduced, giving
the government the ability to take all necessary economic, financial, social or
environmental measures needed to curb the spread of the virus and ensure
the protection of the population (33). This Decree also provides penalties
for anyone found to contravene the orders and decisions of the authorities.
The proclamation of a state of health emergency for an initial period of one
month was accompanied by general movement restrictions.

At the initiative of His Majesty King Mohammed VI, the first support measure
was the creation of a special fund endowed with 10 billion dirhams
(approximately US$ 1 billion) to increase the capacity of the health system and
support the economy. Authorities drew on the resources of the COVID-19 fund to
compensate households in the formal sector who were in financial difficulty.
Each employee who was momentarily out of work recieved a lump sum
payment of 2000 dirhams (approximately US$ 195).

To ensure patient care and the protection of the population, the MoH secured
the availability of essential medicines and personal protective equipment (PPE)
(34–36). Resources were allocated to purchase medical and hospital equipment,
drugs and medical consumables, and strengthen the operating resources of
the MoH (37, 38). The MoH also took measures to increase and redevelop
hospital capacities and improve the conditions for the reception of all patients
in various cities (39, 40). Military field hospitals were deployed in cities or on
their outskirts to reinforce the civilian health system with beds and intensive
care equipment (41), while medical and health equipment were quickly imported
and deployed in health establishments (42). Domestic companies specializing in
the manufacture of medical equipment (e.g., respirators, material resources for
hospitals) were called upon to accelerate production, and other companies
were able to adapt their operations to produce respirators and masks (42).
Stocks of essential drugs were also increased (43).

5
 How primary care and essential public health functions
are responding to COVID-19

As the pandemic progressed, the definition of suspected cases to identify

people infected with COVID-19 was subject to successive revisions (44).
The MoH gradually strengthened its screening capacities by expanding the
purchase of screening kits and the acquisition of various rapid diagnostic tests
(44). Meanwhile, the territorial coverage of tests was extended to include
University Hospital Centres (CHUs) in various regional cities and military
hospitals (45). The population was offered free access to screening tests,
and admission to hospitals and to hotels for patients placed in isolation (43).
A national vaccination strategy was established with provisions for
participation in clinical trials, for the purchase of vaccinations and for
technology transfer.

To reduce the impact of the COVID-19 pandemic on access to services, the MoH
in April 2020 requested that regional directors and health delegates maintain
coverage rates for the national maternal, newborn, child, youth and special
needs programmes. A committee was then formed to monitor the continuity of
the delivery of national health programmes for the prevention and control of
diseases. The MoH informed the public that, despite the epidemic situation,
child vaccination activities were being maintained in public health centres and
private medical practices, while a new appointment mechanism was
established for maternal and neonatal health services to promote access. The
authorities also took measures to ensure the continuous supply of the health
service with contraceptive products, micronutrients, vaccines and medico-
technical equipment necessary to maintain the continuity of essential PHC
services and to avoid possible stockouts.

Online training was provided to health personnel on the management of

pregnancy, childbirth and postpartum care. Stakeholders reported that this
training was comprehensive and targeted, with good engagement at training
sessions. National guidelines and technical procedures were also developed
on the organization and management of pregnancy, childbirth and postpartum
care. Hygiene, safety, prevention and control measures were also introduced
into services and health structures and access to PPE was supported. The MoH
organized online seminars on prevention and control measures for health
professionals, with the support of WHO.

However, like all countries in the world, Morocco was not spared the impact
of the COVID-19 pandemic. A study conducted by the Haut Commissariat au
Plan (HCP) shows that 48% of all households with one or more members
suffering from chronic diseases and 40% of households affected by ordinary
disease did not have access to health services during the period when
movement restrictions were in place (46). In addition, all maternal and child
health activities were impacted by COVID-19. A decrease in the rate of these
activities was observed in the first half of 2020 compared to the first half of 2019
(46). The pandemic also impacted cancer screening activities. Indeed, the
administration of cancer screening tests was suspended for at least 30 days
when stay-at-home orders were enforced and the activity of cancer screening
services decreased by 70% compared to the pre-COVID-19 period (47).

6
 Morocco: a primary health care case study
in the context of the COVID-19 pandemic

Communication with the public involved the development of awareness

materials for the media and social networks based on WHO guidelines for
many topics (e.g., continuity of the use of essential services and care for
children, management of sick children at home, continuity of care for children
with co-morbidities and psychological support for children during
confinement). Virtual conferences were also held on preventive measures and
behavioural responses to mental health problems induced by confinement, on
violence and confinement, on good nutritional practices and on continuity of
care for children with chronic diseases. At the time of writing, no evaluations
had yet been conducted on the population’s response to the official digital
information provided.

In addition to its core activities, primary care was responsible for COVID-19
screening and diagnosis, case investigation and contact tracing, orientation of
cases requiring hospital care, follow-up of cases, reporting of cases,
sensitization and education of the population, and the COVID-19 vaccination
campaign. The use of telemedicine for consultations, especially for women of
reproductive age, aimed to improve service accessibility. In April 2020, the MoH
launched a free voluntary national service based on medical teleconsultation
through an electronic platform – www.tbib24.com. This involved volunteer
doctors in different specialties giving remote medical advice to citizens at the
national level and on a complimentary basis for cases not requiring a particular
diagnosis. In parallel, a specific protocol for suspected and probable COVID-19
cases was established in health centres.

The COVID-19 response also benefited from an early detection and response
system established in 2017 to detect, prepare for and respond quickly to public
health emergencies (48). This involved the creation of a National Centre for
Public Health Emergency Operations (CNOUSP), Regional Centres for Public
Health Emergency Operations (CROUSP) and Multidisciplinary Rapid Intervention
Teams (EIR) at the level of each of the regions, provinces and prefectures.

Finally, as part of the national solidarity campaign, several clinics nationwide

volunteered to assist public hospitals in managing the virus (49, 50). Measures
included the elaboration of a list of volunteer doctors from the private sector to
reinforce medical resources in case of need as the pandemic progressed;
reinforcement of the equipment available to public hospitals, especially
respirators and monitors; management and monitoring of patients with
pathologies other than COVID-19 and pregnant women; and management of
possible cases of COVID-19 contamination.

7
 How multisectoral policy and action are
responding to COVID-19

How multisectoral policy and action are

responding to COVID-19

The MoH played an integral role in steering the health sector response to the
pandemic at national and territorial levels. Within a national governance plan for
responding to health emergencies, and leveraging pre-COVID-19 health system
capabilities, the MoH developed agreements, mechanisms and processes
to facilitate communication and coordination among key government and
nongovernment stakeholders.

To support the COVID-19 response, a Multisectorial Action Plan (43) was

established around three priority areas: health, the economy and social
order. In parallel, national, regional and prefectoral governance plans were
established to manage and coordinate activities and measures between the
relevant actors and stakeholders. A national, regional and prefectoral Command
and Coordination Post (CCP) was also established. The national CCP was
composed of four ministries: the Ministry of the Interior, the MoH, the Ministry of
Economy and the Ministry of Transport. The mission of the national CCP was to
monitor and coordinate, with the health service, efforts to identify and localize
COVID-19 clusters, and to implement measures to manage the pandemic and
its socioeconomic consequences. The regional CCP was composed of regional
ministry representatives. Supporting this at the level of each prefecture was a
series of health command posts were established. The objectives of the regional
and prefectoral CCPs were to coordinate actions to manage the spread of
COVID-19 and the daily processing of information related to the epidemiological
situation. These tasks were overseen by the national and territorial governance
plans, which enabled better coordination of actions and measures between key
stakeholders (39, 43).

The Royal Armed Forces (RAF) also implemented a rigorous and progressive
action plan from the beginning of the pandemic (51). The government mobilized
security services and local administrative authorities to ensure compliance
with containment measures, including movement restrictions. Military medical
resources were utilized to reinforce medical structures dedicated to the
management of COVID-19, which meant that a large number of medical,
paramedical and social services personnel from the RAF were stationed at
hospitals. Military hospitals were also restructured to receive both civilian and
military patients. In addition, the RAF launched, in coordination with the Ministry
of Interior, a 24-hour telephone platform, “Allô 300”, where military doctors and
teleconsultants provided citizens with advice and information on COVID-19.

Multisectoral collaboration also involved the implementation of a strategy to

ensure the continuity of education provision in primary schools, colleges, high
schools and universities. The government established a protocol to guarantee
pedagogical continuity at the elementary level, and in higher education
institutions courses were delivered via videoconferencing to facilitate
educational continuity. Specific measures introduced included:

8
 Morocco: a primary health care case study
in the context of the COVID-19 pandemic

• the launch of the TelmidTICE internet portal to provide digital content,

classified according to the branches of study, levels and subjects taught;

• mobilization of national television channels Attakafia, Laayoune, Amazighia

and Arriadia, which enabled the delivery of courses via video across all levels
of study;

• implementation of a participatory service to allow teachers to communicate

directly with their students and to organize distance learning sessions;

• the launch of digital platforms for higher education to allow students to

interact with their teachers, in addition to courses being broadcast on
television and radio.

Low attendance was the main constraint for this distance learning model. In this
context, 52% of teachers interviewed in a study felt that attendance was low to
very low. The standard of living in households, lack of access to technology and
the rural environment were the main reasons noted for student absences (52).

Efforts to strengthen PHC during the pandemic were supported financially by

international organizations (WHO, the United Nations Children’s Fund (UNICEF),
the Spanish Agency for International Development Cooperation (AECID) and
the Global Fund) within the framework of international cooperation in 2020
(53). Direct financial contributions from these donors amounted to more than
1.96 billion dirhams (approximately US$ 190 000) in 2020. The support focused
on the synthesis of strategic priorities resulting from a forum on PHC, initiation
of the process to develop a vision and a National PHC Strategy, the acquisition
of medico-technical equipment necessary for the continuity of essential PHC
services, strengthening of PHC structures, and the development of PHC safety
guidelines and tools to monitor and evaluate their implementation. These
efforts demonstrate that pre-established links with regional and global health
authorities and international development and humanitarian agencies was a key
factor to secure medical supplies and vaccines, and in training its health care
workforce during the pandemic.

Technical and financial partners supported the national efforts to respond

to the COVID-19 pandemic by contributing a budget of 120.91 billion dirhams
(approximately US$ 11.8 million) in 2020, which included direct and in-kind
donations. This support was utilized to strengthen health infrastructure and
national laboratories, to implement communication strategies, and to build
capacity in disease prevention, infection control and patient care. Budgetary
support was also mobilized in the form of grants from WHO and the European
Union; loans from the African Development Bank, the World Bank, the Islamic
Development Bank and the European Investment Bank; and international
cooperation with Japan and the Arab Fund for Economic and Social Development.

The hotel network also showed solidarity during the pandemic response, with
some establishments taking the initiative and others asked by the national
authorities to make their hotel units available to both health personnel mobilized
to respond to the pandemic and to patients. Accommodation was often made
available free of charge (54).

9
 How communities are responding
to COVID-19

How communities are responding to COVID-19

A communication plan was developed during the COVID-19 pandemic to support

the provision of continuous information via the media on the health situation,
as well as the production of information kits in national and foreign languages,
the development of educational materials for awareness-raising in schools,
and the dissemination of targeted information for public and private health
professionals (53).

Engagement and communication with communities took place at local, national

and territorial levels. Official and traditional media channels were used, plus
digital platforms such as WhatsApp. Daily active monitoring via WhatsApp
of those in contact with a confirmed positive case was supplemented with
quarterly surveys (55). These measures made it possible to monitor the response
efforts in communities and implement new strategies as needed. The enrichment
of communication channels through new technologies also made it possible to
integrate community feedback into activities, responses and policies at all levels.

The majority of primary care centres engaged with their communities to

disseminate health education and awareness messages on COVID-19, including
updates on the vaccination deployment plan. All primary care centres worked
with local government officials to disseminate health awareness campaigns, and
some also worked with schools and volunteers to do the same.

New strategies were developed to manage the stress and mental health
needs of communities stemming from the introduction of movement restriction
policies. In this context, efforts were made to enable access to professional
psychological assistance to the most vulnerable groups. Psychiatrists,
psychology professionals and volunteer initiatives set up several digital
platforms to provide psychological support and counselling services to citizens
who developed severe anxiety, depression or acute panic disorder resulting from
the new conditions of confinement (56). Civil society organizations also mobilized
their capacities to support the elderly, to combat violence against women and
children, to support students who experienced difficulties in engaging in their
distance-learning courses, and to provide social protection to vulnerable groups.

The media, the scientific community, medical professors and health care
professionals all played a key role in encouraging the community to get tested
for the virus and to engage in the national COVID-19 vaccination campaign.
To facilitate the involvement of the academic community, the MoH set up a
scientific committee that informed the strategies, actions and measures of the
government. In addition, learned societies (including the Moroccan Society of
Medical Sciences, the Moroccan Society of Pediatrics, the Moroccan Society
of Infectiology and Vaccinology, and the Moroccan Society of Anesthesia,
Analgesia and Resuscitation) contributed to the development of protocols for the
management of children and pregnant women as well as for the management
of COVID-19 cases in general, severe and critical cases. The teaching community

10
 Morocco: a primary health care case study
in the context of the COVID-19 pandemic

also contributed in raising awareness and educating the population about

COVID-19 through interventions in various media.

In sum, primary care played a critical role in community engagement and public
awareness, enabling participation in response efforts and facilitating community
trust in health services

Conclusion and lessons learned

The COVID-19 pandemic revealed major limitations in the health system. It

exacerbated pre-existing weaknesses and inflicted a significant burden of
disease and social and economic costs on individuals and the country. However,
Morocco reorganized its health system and proactively pursued multisectoral
collaboration and community engagement to support the response effort.

Against a backdrop of limited health resources, Morocco proactively deployed

action plans at several levels to minimize the health and socioeconomic
consequences of COVID-19. The MoH was an integral component in steering the
health sector response to the pandemic at the national and territorial level, with
agreements, mechanisms and processes introduced to facilitate communication
and coordination among key government and nongovernment stakeholders.
This is critical to build resilience and preparedness in a health system and
to mount an effective response in emergencies. Centralized management
shaped the capacity of the government to lead the pandemic response, to
coordinate multisectoral action and to minimize duplication and inefficiency.
The establishment of expert technical and scientific advisory committees also
helped to define patient management protocols and a communication strategy,
enabling evidence-informed decision-making.

Understanding the importance of PHC, Morocco put in place several mechanisms

to maintain essential PHC activities and provide the PHC system with the
resources and means necessary to respond effectively (57, 58). Pre-established
links with regional and global health authorities and with international
development and humanitarian agencies were key to securing medical supplies
and vaccines and training the health care workforce during emergencies. The
crisis has also underscored the importance of multisectoral collaboration and
community engagement.

Continuous dialogue between policy-makers, health care professionals, public

health experts, communities, nongovernmental organizations, citizens, the
private sector, researchers, funders and other relevant stakeholders could help
to ensure these key lessons from the pandemic are embedded in PHC policy.
The findings of this case study can be used to inform future policy and
programme planning to deliver effective health services during public health
crises and to build a more resilient health system.

11
 References

References

1. From Alma-Ata to Astana: PHC – reflecting on the past, transforming for the future.
Geneva: World Health Organization (WHO); 2018 (https://apps.who.int/iris/
handle/10665/345685).

2. Plan national de veille et de riposte à l’infection par le Coronavirus 2019-nCoV. Rabat:

Ministry of Health (MoH); 2020 (https://www.sante.gov.ma/Documents/2020/
coronavirus/Plan%20national%20de%20veille%20et%20de%20riposte%20
%C3%A0%20l%27infection%20par%20le%20Coronavirus%202019-nCoV.pdf).

3. International Health Regulations Emergency Committee on Novel Coronavirus in China.

Geneva: WHO; 30 January (https://www.who.int/news-room/events/detail/2020/01/30/
default-calendar/international-health-regulations-emergency-committee-on-novel-
coronavirus-in-china).

4. Brueck H. The coronavirus has pandemic “potential” as it spreads in South Korea, Italy,
and Iran, according to WHO. Business Insider; 24 February (https://www.businessinsider.
com/covid-19-coronavirus-has-pandemic-potential-says-who-2020-2?IR=T).

5. The WHO still isn’t describing Covid-19 as a pandemic. New Scientist; 24 February 2020
(https://www.newscientist.com/article/2235095-the-who-still-isnt-describing-covid-
19-as-a-pandemic/#ixzz6F2fq8ncn).

6. WHO Director-General’s opening remarks at the media briefing on COVID-19. Geneva:

WHO; 11 March 2020 (https://www.who.int/dg/speeches/detail/who-director-general-
s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020).

7. Lupia T, Scabini S, Mornese Pinna S, Di Perri G, De Rosa FG, Corcione S. 2019-novel

coronavirus outbreak: a new challenge. J. Glob. Antimicrob. Resist. 2020;21:22–27.

8. Jartti L, Langen H, Söderlund-Venermo M, Vuorinen T, Ruuskanen O, Jartti T. New

respiratory viruses and the elderly. Open Respir. Med. J. 2011;5:61–69.

9. Rabi FA, Al Zoubi MS, Kasasbeh GA, Salameh DM, Al-Nasser AD. SARS-CoV-2 and
coronavirus disease 2019: what we know so far. Pathogens. 2020;9:231.

10. Coronavirus disease (COVID-19) overview. Geneva: WHO; 2020.

11. Coronavirus disease 2019 (COVID-19): how to protect yourself and others. Atlanta (GA):
Centres for Disease Control and Prevention; 2020.

12. Operational framework for PHC: transforming vision into action. Geneva: WHO; 2020.

13. High-level event: the role of PHC in the COVID-19 pandemic response and leading
equitable recovery. Geneva: Universal Health Coverage Partnership; 2021.

14. Strengthening the frontline: how PHC helps health systems adapt during the COVID 19
pandemic. OECD Policy Responses to Coronavirus (COVID-19). Paris: OECD Publishing
(https://doi.org/10.1787/9a5ae6da-en).

15. Comptes nationaux de la sante – 2018. Rabat: Direction De La Planification Et Des

Ressources Financières; 2018.

16. Stratégie nationale de financement de la santé. Rabat: MoH; April 2021.

17. Rasanathan K, Evans TG. PHC, the Declaration of Astana and COVID-19. Bulletin of the
WHO. 2020;98(11):801.

18. Barkley S, Marten R, Reynolds T, Kelley E, Dalil S. PHC: realizing the vision. Bulletin of the
WHO. 2020;98(11):727.

19. Annuaire statistique du maroc principaux indicateurs statistiques 2020. Rabat: HCP
Maroc; 2020.

20. Santé en chiffre 2019. Rabat: MoH; 2019 (https://www.sante.gov.ma/

Documents/2021/12/Sante%20en%20chiffres%202019%20.pdf)

12
 Morocco: a primary health care case study
in the context of the COVID-19 pandemic

21. Enquête nationale sur la population et la santé familiale 2018. Rabat: MoH; 2018.

22. Les soins de santé de base: vers un accès équitable et généralisé 2013. Rabat: Conseil
Economique, Social et Environnemental – Maroc; 2013.

23. Constitution of Morocco 2011. Rabat: Government of the Kingdom of Morocco; 2011.

24. Rapport: activité, emploi et chômage: quatrième trimestre 2021. Rabat: HCP Maroc; 2021.

25. Projet de réforme. Rabat: MoH; 2020.

26. PHC organization. Rabat: MoH; 2020.

27. loi cadre n° 34.09 du 2 Juillet 2011 relative au système de santé et à l’offre de soins au
Maroc. Rabat: Government of the Kingdom of Morocco; 2011.

28. Zahidi K, Moustatraf A, Zahidi A, Naji S, Obtel M. Universal health coverage in Morocco:
the way to reduce inequalities: a cross-sectional study. The Open Public Health Journal;
2022;15.

29. Rapport de suivi de la situation économique (Avril 2022). Rabat: Banque Mondiale –
Maroc; 2022.

30. Coronavirus nombre de cas au Maroc. Paris: Coronavirus Statistiques; n.d. (https://
www.coronavirus-statistiques.com/stats-pays/coronavirus-nombre-de-cas-maroc/).

31. Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, et al.

Coronavirus pandemic (COVID-19). Our World in Data; 5 March 2020 (https://
ourworldindata.org/covid-vaccinations).

32. Decree-Law No. 2.20.292 of 2020 regarding the enactment of provisions related to the
State of Health Emergency and the procedures for declaring them. Rabat: Government
of the Kingdom of Morocco; 23 March 2020 (https://leap.unep.org/countries/ma/
national-legislation/decree-law-no-220292-2020-regarding-enactment-provisions-
related).

33. Decree No. 2.20.293 of 2020 declaring a State of Health Emergency throughout the
national territory to confront the outbreak of the Coronavirus-Covid 19. Rabat:
Government of the Kingdom of Morocco; 24 March 2020 (https://leap.unep.org/
countries/ma/national-legislation/decree-no-220293-2020-declaring-state-health-
emergency-throughout).

34. Sylla A. Coronavirus: pourquoi le Maroc a réquisitionné le stock de nivaquine et de

plaquenil du laboratoire sanofi. Challenge.ma; 19 March 2020 (https://www.challenge.
ma/covid-19-pourquoi-le-maroc-a-requisitionne-le-stock-de-nivaquine-et-de-
plaquenil-du-laboratoire-sanofi-133130/).

35. Handaoui K. Coronavirus: 500 respirateurs 100% marocains prêts la semaine

prochaine. Challenge.ma; 7 April 2020 (https://www.challenge.ma/coronavirus-500-
respirateurs-100-marocains-prets-la-semaine-prochaine-136386/).

36. 36. Lutte contre le Covid-19: la fabrication des masques de protection en tissu non
tissé soumise à l’obligation normative. Rabat: Ministry of Industry and Commerce;
2020 (http://www.mcinet.gov.ma/fr/content/lutte-contre-le-covid-19-la-fabrication-
des-masques-de-protection-en-tissu-non-tiss%C3%A9-soumise).

37. Création d’un fonds spécial dédié à la gestion de la pandémie du Coronavirus « La

Covid-19 ». Rabat: MEF – Royaume du Maroc; n.d. (https://www.finances.gov.ma/fr/
Pages/detail-actualite.aspx?fiche=4970).

38. Stratégie nationale du financement de la santé 2021. Rabat: MoH and Ministry of Social
Protection; 2021.

39. Un an de gestion de la pandémie Covid-19. Rabat: MoH and Ministry of Social

Protection; 2021.

13
 References

40. Le ministère de la Santé aloue un important lot de matériel médical anti-Covid à

l’hôpital régional de Laâyoune. Maroc.ma; 4 December 2020 (https://www.maroc.ma/
fr/actualites/le-ministere-de-la-sante-aloue-un-important-lot-de-materiel-medical-
anti-covid-lhopital).

41. Covid-19: L’hôpital de campagne de Benslimane prêt à entrer en action à tout moment.
Maroc.ma; 2 April 2020 (https://www.maroc.ma/fr/actualites/covid-19-lhopital-de-
campagne-de-benslimane-pret-entrer-en-action-tout-moment).

42. Covid-19: Au Maroc, une riposte teintée de lucidité et des réponses en adéquation avec
les enjeux de cette crise sanitaire. Maroc.ma; 5 May 2020 (https://www.maroc.ma/fr/
actualites/covid-19-au-maroc-une-riposte-teintee-de-lucidite-et-des-reponses-en-
adequation-avec-les).

43. Ali AA, Bassou A, Dryef M, Aynaoui KE, Houdaigui RE, Jai YE, et al. La stratégie du Maroc
face au Covid-19. Rabat: Policy Centre for the New South; 2020 (https://www.
policycenter.ma/publications/la-strat%C3%A9gie-du-maroc-face-au-covid-19).

44. Mise à jour de la définition de cas d’infection au SARS-CoV-2 (COVID-19). Rabat: MoH; 2020.

45. La stratégie du Maroc face au Covid-19. ITICOM.Co; n.d. (https://www.ituc-africa.org/

La-Strategie-Du-Maroc-Face-Au-Covid-19.html).

46. Enquête sur l’impact du coronavirus sur la situation économique, sociale et

psychologique des ménages. Rabat: Haut-Commissariat au Plan du Royaume du
Maroc; 2020 (https://www.hcp.ma/Enquete-sur-l-impact-du-coronavirus-sur-la-
situation-economique-sociale-et-psychologique-des-menages-Note-de-synthese _
a2506.html).

47. Villain P, Carvalho AL, Lucas E, Mosquera I, Zhang L, Muwonge R, et al. Cross-sectional
survey of the impact of the COVID-19 pandemic on cancer screening programs in
selected low- and middle-income countries: study from the IARC COVID-19 impact
study group. Int J Cancer. 2021 Jul 1;149(1):97–107.

48. Ministry of Health circular: Décision du Ministère de la santé N 013065 du 16 septemebre

2019 portant sur la création d’un centre national d’opération d’urgence en santé
publique (CNOUPS), des centres régionaux d’opération d’urgence de santé publique
(CROUPS) et instituant les equipes d’intervention rapide (EIR). Rabat: MoH; 2019.

49. Covid-19: Une clinique privée apporte son soutien aux hôpitaux publics. MapMarrakech;
30 March 2020.

50. Mountaj I. Les cliniques privées détaillent leurs contributions à la lutte contre le Covid.
Médias24; 5 June 2020 (https://medias24.com/2020/06/05/les-cliniques-privees-
detaillent-leurs-contributions-a-la-lutte-contre-le-covid/).

51. Covid-19, le temps d’agir et de réagir. Revue des Forces Armées Royales. n.d.; edition
397 (https://revue.far.ma/storage/revues/RevueE397.pdf).

52. Rapport enseignement au temps de COVID. Rabat: UNICEF; 2021 (https://www.unicef.

org/morocco/media/2581/file/Rapport%20Enseignement%20au%20temps%20
de%20COVID).

53. Coopération en santé 2020. Rabat: MoH; 2020 (https://www.sante.gov.ma/

Documents/2022/03/coop%C3%A9ration%20en%20sant%C3%A9%202020.pdf).

54. Casablanca: 2.100 lits d’hôtel pour le corps médical et 900 pour les patients. Médias24;
28 April 2020 (https://medias24.com/2020/04/28/casablanca-2-100-lits-dhotel-pour-
le-corps-medical-et-900-pour-les-patients/).

55. Guide de gestion des contact. Rabat: MoH; 2020 (https://www.sante.gov.ma/

Documents/2020/coronavirus/PS/Guide _ gestion _ contact.pdf).

56. Coronavirus: PsyPhone propose une assistance psychologique à distance

gratuitement. Challenge.ma; 27 March 2020 (https://www.challenge.ma/coronavirus-
psyphone-propose-une-assistance-psychologique-a-distance-gratuitement-134727/)

14
This case study was developed by the Alliance for Health Policy
and Systems Research, an international partnership hosted by the
World Health Organization, in collaboration with the WHO Regional
Office for the Eastern Mediterranean (EMRO) and WHO country
offices. In 2015, the Alliance commissioned the Primary Health Care
Systems (PRIMASYS) case studies in twenty low- and middle-
income countries (LMICs) across WHO regions. This case study
builds on and expands these previous studies in the context of the
COVID-19 pandemic, applying the Astana PHC framework
considering integrated health services, multisectoral policy and
action and people and communities. This case study aims to
advance the science and lay a groundwork for improved policy
efforts to advance primary health care in LMICs.