The Economy of Mental Health: Inequalities in Access to Care in Morocco

In 2005, Morocco’s Ministry of Health (Ministère de la Santé) carried out its first-ever epidemiological survey of mental illness in the country. As a Bulletin de Santé later reported, the study found that about fifty percent of the population had suffered from at least one minor psychiatric ailment over the course of their lives:

… one in two Moroccans presents with at least one significant sign of impaired mental health, regardless of its degree of severity, ranging from a simple nervous tic or occasional insomnia to more serious manifestations of anxiety or depression.[1]

This number lies within range of the global average, and is not terribly surprising in and of itself. But nearly ten years after publication of this bulletin, a majority of Moroccans who suffer from mental illness still do not receive adequate care – and many never get to see a psychiatrist at all.

Mechanisms of Inequality: Why Access to Care is More Difficult for Some than Others

Several reasons might be cited for this lack of therapeutic intervention. One probable factor, for example, is a lack of willingness to seek out mental health treatment. Within a public health system already associated with a poor standard of care and unavoidable corruption, psychiatry suffers from an especially negative reputation; it still has not fully managed to shed a problematic colonial legacy of severe treatments, racism, and long, involuntary hospitalizations.[2] Another factor likely to keep people away from psychiatrists’ offices is a lack of public knowledge about mental illness. Among a large percentage of the population, the nature of major psychiatric diagnoses such as schizophrenia or bipolar disorder are poorly understood at best; at worst, individuals afflicted by one of these illnesses suffer the significant stigma of being labeled as hmeq, or "crazy."

However, one of the most acute impediments to receiving good quality psychiatric care – and one that tends to exacerbate the impact of the other factors just mentioned – is a lack of availability and a marked inequality of access to the resources that do exist. Despite recent efforts by the Ministère de la Santé to improve both the quality and quantity of psychiatric services, good mental healthcare in Morocco generally remains difficult to obtain for any but those who belong to the country’s upper socio-economic classes. This uneven access not only reflects, but also has the potential to further entrench, fundamental inequalities present in Moroccan society.

Morocco’s historic division into bled el makhzen and bled as-siba continues to leave its mark on the nationwide distribution of healthcare resources – just as it still impacts the reach of other government services and social goods. The anchoring points of the public healthcare system are a network of regional Etablissements de Soins de Santé de Base (ESSBs), or small primary health clinics. As of 2010, 2626 such clinics were in operation around the country, in addition to about 140 larger government hospitals and clinics concentrated in urban areas. The ESSBs are specifically meant to constitute a decentralized system that makes basic care accessible to everyone. In practice, however, the distribution of these ESSBs across the country remains uneven: as much as seventy percent of Morocco’s rural population must travel more than five kilometers to reach the nearest healthcare facility, often little more than a dispensary that may not always have a doctor on site.[3]

The distribution of mental healthcare facilities is even more sparse and uneven. The total number of practicing psychiatrists in Morocco is estimated at 350 – which translates into a ratio of about one specialist per 100,000 people – and the vast majority of these doctors practice in the larger Rabat-Casablanca metropolitan corridor. Some of them run private practices, while others are connected to one of the Ministère’s twenty-seven public institutions for mental healthcare; a combination of psychiatric wards within general hospitals, specialized mental health facilities, and psychiatric teaching hospitals. In efforts, once again, to decentralize the nation’s network of mental health resources and favor regional community treatment over large urban institutions, the number of beds available at each of these institutions has been deliberately limited, or even scaled back.[4] However, the Ministère de la Santé has not had the resources to couple this with an expansion of mental healthcare facilities around the country. As a result, these twenty-seven institutions together offer no more than about 1900 beds for mental healthcare nationwide – which amounts to less than one per 17,000 people. Most of these beds are concentrated in Morocco’s larger cities, leaving the country’s rural regions without local access to any mental health resources.

This uneven access to care is exacerbated by the fact that Morocco’s rural population disproportionately belongs to the lower socio-economic classes. Fewer financial resources, combined with longer required travel distances to the closest clinic, mean that residents of rural areas often tend to wait longer before seeking help, and therefore tend to be in worse condition by the time they enter a psychiatrist’s office. As is the case for many other conditions, mental disorders can become more difficult to alleviate when left untreated for a while. This sets up an unfortunate paradox: those who have less access to mental health care often end up in relatively worse condition and are therefore most in need of it.

It is not just the rural poor who are restricted in their access to mental healthcare. The urban poor likewise suffer from a disadvantage – if not because of geographical limitations, then by virtue of Morocco’s national health insurance law. In the early 2000s, the government established a system of basic universal coverage: the Assurance de Maladie Obligatoire (AMO) covers anyone employed in the public or private sector, while a supplementary Régime d’Assistance Médicale aux personnes Economiquement Démunies (RAMED) is available to anyone who cannot pay for healthcare on his or her own and is ineligible for the AMO. Especially with the recent expansion of RAMED coverage, this new system has significantly improved healthcare access for Morocco’s poor populations. Mental healthcare, however, is included neither in the AMO nor in the RAMED. Coverage for psychiatric services would require payment into a more expansive – and therefore more expensive – insurance policy, which is out of financial reach for many of those most in need of assistance. Once again, a tragic paradox ensues: mental healthcare is more costly for those who are less able to pay.

Inequalities in Quality of Care

Even when members of Morocco’s lower socio-economic strata do make it to a psychiatric facility, they are still less likely than those more affluent to receive good quality care. I base the following discussion on fourteen months of ethnographic fieldwork at a psychiatric teaching hospital in the Rabat-Casablanca corridor, where – despite doctors’ best intentions – patients with limited economic resources are likely to receive less adequate care than their wealthier counterparts.

The hospital where I conducted my research is structured into four wards: for men and women each, a "locked" and "open" unit. The former are intended for patients in unstable or critical condition, and who may pose a danger to themselves or others; the latter for those whose illness is more stable or mild. The open units, as their name suggests, are airy and bright, and hold about thirty beds; two each in rooms that let in plenty of sunlight from the lush gardens just beyond. The clinical staff have their offices on the ward itself, which means they are available to patients throughout the day. The locked wards, on the other hand, are for obvious reasons more isolated, but thereby also darker. Little sunlight streams into the units’ cavernous rooms, some of which hold as many as ten beds. These units are much larger: with as many as seventy inpatients, there is very little privacy. Even doctor-patient consultations often take place in public areas on the ward; for reasons of security, patients are rarely brought back to the doctors’ offices, which lie just beyond the ward’s locked doors.

Officially, the reasons for assigning patients to either ward are purely medical: any indication of violence, aggression, or other volatility is grounds to hospitalize someone on the locked ward. In practice, however, individuals from lower socio-economic classes disproportionately end up on these locked units. This results in part from the fact that, as mentioned before, these individuals tend to be in relatively worse condition by the time they seek out help and arrive at the hospital. But it is compounded by the economic realities of hospitalization: admission to the locked wards is free of charge, whereas twenty-four hours on an open ward costs 300 dirhams (about 30 US dollars). This fee structure is a matter of legal necessity: the hospital is required by law to admit anyone in need of urgent treatment, regardless of their ability to pay, but cannot afford to offer free hospitalization to all. However, the unfortunate side-effect is that a stay on the open ward, where the quality of care is generally higher, becomes a precious good that not everyone can afford.

In sum, individuals with fewer financial and other socio-economic resources must also make do with limited access to quality mental health care. They tend to live further away from care providers than those who are more affluent; they are less likely to have insurance that will cover the costs of treatment; and even once they do make it to the hospital, their inability to pay, combined with their tendency to be in worse condition, puts these individuals at risk of receiving insufficient treatment. In other words, quality mental health and healthcare have become economic commodities that some can afford, and others cannot.

This commoditization is especially problematic because a person’s mental health is directly linked to his or her quality of life and ability to access other resources. To begin with, individuals who belong to lower socio-economic strata are more likely than others to encounter mental health problems because they are more likely to be exposed to risk factors for illness, such as the stress of loss, abuse, economic hardship, existential insecurity, and so on – a disadvantage that is only compounded by their relative lack of access to quality care. In turn, a mental health problem tends to further worsen a person’s socio-economic disadvantage: someone with a psychiatric disorder is less likely to find stable employment, complete an education, find a partner, or maintain other supportive relationships. In other words, low socio-economic status can put a person at risk of developing mental health problems, while bad mental health is likely to further disadvantage a person’s socio-economic status.

The Value of Psychiatry

The discussion above concerns access to psychiatric care – and it is important to briefly consider psychiatry’s place within the larger landscape of healing practices in Morocco. Throughout the country, there is a lively practice of so-called "traditional" or "religious" healing methods. Based on a heterodox local Islam, these practices vary widely in both type and scope, from brotherhoods that channel the holy force of a local saint or jinn, to fuqaha who cure with the power of the Qur’an. Healers can be found throughout the country, and easily fill both the geographic and economic gaps left uncovered by psychiatric providers. Moreover, these "traditional" healing methods offer illness explanations that are embedded firmly in the local landscape of cultural beliefs and practices, and therefore could be said to resonate much better than a psychiatric diagnosis with a sufferer’s felt experience of distress. Psychiatric diagnoses, in turn, are often poorly understood at best, and severely stigmatized at worst. In addition, psychiatry has a problematic colonial legacy to contend with – in North Africa, as elsewhere, its medical legitimacy long provided a convenient pretext for the mistreatment, subjugation, and marginalization of indigenous communities.

It is worth questioning, then, whether the receiving of psychiatric healthcare would be at all advantageous to a person’s social and socio-economic status. Indeed, many patients at the clinic where I conducted research expressed concern about how their community might react to their hospitalization at a mental health facility.[5]However, "traditional" healing methods are not without their stigma, either; though possession by a jinn might be a more familiar concept to many local communities than schizophrenia, a person possessed is often no less shamed or marginalized as hmeq than a psychiatric patient is. Furthermore, the heterodox nature of these local treatment methods produces ambivalent responses: though healers may be respected and feared for their connections to the supernatural, they are also widely looked down upon as representatives of marginal, uncivilized, and ignorant practices. In fact, many of the people I worked with objected to the designation of local healing practices as "traditional" or "religious" – preferring instead the term "obscurantist" – lest it be implied these practices have anything to do with mainstream cultural tradition and Islam.

Moroccan psychiatrists have seized upon this ambivalent status of local healing traditions: both in the media and in clinical practice, they invoke the medieval Arab origins of modern medicine and psychiatry in order to claim their discipline’s status as the true heir of an authentically Islamic cultural tradition. Moreover, these psychiatrists have been deliberately engaged over the past few decades in an effort to bolster their local cultural relevance by investigating the specific features of Moroccan illness experience, and highlighting the importance of understanding and attending to the culturally embedded ways in which Moroccan patients experience their symptoms. Indeed, my research found that most local psychiatrists are far less interested in labeling their patients with a (potentially stigmatizing) diagnosis than they are in exploring the sufferer’s particular socio-psychological background, and offering them the mental tools to cope with particular sources of distress. As such, psychiatric treatment in fact can be, and often is, empowering and liberating for patients. It offers them a space to express feelings, and to be heard and validated in their private experience. Psychiatrists often help their patients confront and transform the dynamic of difficult social relationships, facilitating acceptance by and reintegration into the community. Even the psychopharmaceuticals patients are prescribed can help: their chemical tangibility often helps to legitimize an illness as a "real" medical problem, worthy of social understanding and a little special dispensation. In other words, (quality) mental health treatment truly can be beneficial to those who suffer from psychological distress – but only if they have the means to access these services.

Conclusion

Inequalities of access to care do not affect the specialty of psychiatry alone (nor are they unique to Morocco). However, given the intractable nature of many psychiatric disorders and their immense impact on a sufferer’s quality of life, compounded by the fact that they remain so poorly understood and stigmatized by such a large percentage of the population, the problem of unequal access to mental healthcare is particularly acute, and can thwart efforts to reduce inequality in other arenas of civil society. Fortunately, efforts are certainly being made to improve both the quality and quantity of psychiatric resources in Morocco. For a number of years now, native psychiatrists have been engaged in a campaign to educate both the public and policymakers about the importance of good mental health. Taking to the media, they have made efforts to explain the nature of mental illness, and to assert both the cultural and scientific legitimacy of their medical practice. The Ministère de la Santé, in turn, has in recent years declared psychiatry a national priority, and dedicated a growing budget share to the specialty. Psychiatric training has been expanded: the discipline is now a required rotation for all medical students, and more slots for residency training are being added every academic year. In addition, funds are being dedicated to the improvement of existing mental healthcare facilities as well as the construction of new ones.

Nevertheless, further work is necessary to truly render mental healthcare available to all who need it. “Effective interventions are available,” the Ministère’s 2005 study of mental health concludes,

due to the evolution of therapeutic methods and health systems, but the majority of those in need of treatment are [still] unable to access it. They would be able to if the surrounding politics and legislation evolved, if the [necessary] services were put into place, if adequate financing was secured, and if sufficient personnel were trained.

The work of developing additional resources – of opening more clinics and training more psychiatrists – will have to continue over years to come in order to adequately and equally provide for the country’s entire population. But while the nationwide lack of (quality) resources must certainly be addressed, the problem of unequal access will never be fully solved unless the issue of cost is also addressed. Only when psychiatric services are incorporated into both AMO and RAMED coverage, and when hospital payments are administratively de-coupled from one’s designation to a particular ward, will mental healthcare truly be available to all.

[This article was originally published on Farzyat/Inégalités]

For more information, see:

F. Asouab, M. Agoub, N. Kadri, D. Moussaoui, S. Rachidi, M.A. Tazi, J. Toufiq & N. Chaouki (2007), Prévalences des Troubles Mentaux dans la Population Générale Marocaine (Enquête Nationale, 2005), Rabat: Direction de l’Epidémiologie et de Lutte Contre les Maladies – Bulletin Epidémiologique du Ministère de la Santé, Décembre 2007

Bennani, Jalil (1996), Psychanalyse en Terre d’Islam: Introduction à la Psychanalyse au Maghreb, Casablanca: Editions Le Fennec

Conseil National des Droits de l’Homme (2012), Santé Mentale et Droits de l’Homme: l’Impérieuse Nécessité d’une Nouvelle Politique. Rapport Préliminaire, Rabat: CNDH

R. Desjarlais, L. Eisenberg, B. Good & A. Kleinman (1995), World Mental Health: Problems and Priorities in Low-Income Countries, New York: Oxford University Press

F. Fanon, (1972 [1959]), Sociologie d’une Révolution (L’an V de la Révolution Algérienne). Paris: François Maspéro

P. Farmer, (2005), Pathologies of Power: Health, Human Rights, and the New War on the Poor, Berkeley: University of California Press

B. Fikri, Noureddine (2012), Monographie Nationale: Maroc. Les Systèmes de Santé en Algérie, Maroc et Tunisie: Défis Nationaux et Enjeux Partagés, Paris: Les Notes IPEMED: Etudes & Analyses 13: 82-100

R. Keller, (2007), Colonial Madness: Psychiatry in French North Africa, Chicago: University of Chicago Press

Ministère de la Santé (2012), Etat de Santé de la Population Marocaine 2012, Rabat: Ministère de la Santé.

F-Z. Sekkat & S. Belbachir (2009), “La Psychiatrie au Maroc: Histoire, Difficultés et Défis”, L’Information Psychiatrique 85:605-610

H. Semlali, (2010). Etude de Cas : Maroc. Environnements de Soins de Santé au Maroc. Environnements Favorables à la Pratique au Maroc. Genève: OMS Alliance Mondiale Pour les Personnels de Santé