The incidence of catastrophic and impoverishing health spending in Morocco: the value added of new methodologies

One of the key objectives of the Moroccan government in achieving universal health coverage (UHC) in Morocco is to improve household financial protection against catastrophic health expenditure (CHE). However, there is no consensus on how to measure CHE. Moreover, measuring CHE using traditional methods poses a challenge for equity analysis and pro-poor policy initiatives. Therefore, this paper aims to conduct an in-depth national analysis to inform policymakers about the extent, distribution and causes of financial hardship. In addition, this study aimed to explore the equity and policy implications of different capacity-to-pay (CTP) methodologies for calculating CHE in Morocco. We present estimates of catastrophic and impoverishing health spending incidence using different methods. These methods include (i) the budget share method (BS method), (ii) the partial normative food expenditure method (Normative food method), (iii) Wagstaff and Eozenou’s approach (WAE approach), and (iv) the normative food, housing (rent), and utilities (FHU) method (WHO EURO method). The data comes from the 2014 Moroccan National Household Consumption and Expenditure Survey (NHCES). To measure changes in financial protection between the four calculation methods, we also use a weighted financial protection index (FP index) and another index measuring the fairness of financial contributions (FFC). CHE incidence estimates were similar using the WHO EURO method and the BS method at the threshold of 15% of a household's CTP. The estimate of impoverishing out-of-pocket payments (OOP) was 1.31% when using the food poverty line (FOOD-PL) and 1.93% when using the FHU poverty line (FHU-PL). In addition, the further impoverishing OOP estimate was 3.39% and 5.41% using the FOOD-PL and FHU-PL, respectively. The study shows that, unlike the new methods, conventional methods overestimate the financial burden of the better-off. The BS method suggests that the Moroccan health system is egalitarian, while the new approaches suggest that it meets normative equity objectives. The FP index and the FFC decrease as the poverty line rises. Medicine is the first driver of financial hardship. The monetary transfer needed to compensate for the impoverishment caused by OOP is about 141 MAD and 269 MAD per person per year, using FOOD-PL and FHU-PL, respectively. The results suggest that the health insurance system should be reviewed to further reduce CHE and impoverishment in Morocco. The use of the BS method to track target 3.8.2 of the SDGs raises concerns about the ability of the SDG process to generate appropriate policy guidance on UHC. Studies using different approaches. such as this one. are expected to facilitate informed decision-making and prevent potential political manipulation in demonstrating the success or failure of a policy. Highlights • Our study evaluates the equity implications of different CTP methods for estimating CHE in Morocco. • Traditional methods systematically overstate the financial burden on wealthier households. • The WHO EURO methodology provides the most accurate assessment, capturing both the regressive nature of CHE incidence and the progressive pattern of OOP/CTP. • Findings reinforce the importance of Morocco’s ongoing health financing reforms to reduce out-of-pocket payments. • Future research should incorporate forgone care and coping strategies to enhance financial protection analysis.