Health Financing, Income, and Population Health in Morocco (2000–2022): Contrasting Evidence from Life Expectancy and Infant Mortality in an Exploratory ARDL Framework

Abstract

Abstract

Background. Over roughly twenty years, a series of financing reforms has redrawn Morocco's social protection system. The path runs from the creation of the Assurance Maladie Obligatoire (AMO) through to the generalization of compulsory coverage under Framework Law 09-21 and, more recently, the launch of AMO-Tadamoun. The trouble is that direct household out-of-pocket payments still take up about 41% of current health expenditure. That figure is close to three times the level internationally associated with low financial hardship, which suggests that signing people up has not yet delivered real financial protection. Whether these reforms have produced measurable health gains is still an open question, and aggregate macroeconomic data offer at least a first way into it.

Methods. We work with annual national data for Morocco covering 2000 to 2022, built around two outcomes rather than one. An ARDL bounds testing framework is estimated separately for life expectancy at birth and for the infant mortality rate. We then re-check the long-run cointegrating vector with Fully Modified OLS and Dynamic OLS, so as to deal with the endogeneity that remains in the regressors.

Results. Most of what matters here comes from the infant mortality model. Three independent estimation methods point the same way: a heavier out-of-pocket burden is associated with worse child survival, higher income with lower infant mortality, and higher public health spending with lower mortality once its endogeneity is taken into account. The life expectancy model behaves quite differently. Because that series barely shifts from one year to the next, it cannot pin down these effects at all, and the gap between the two models tells us something useful in its own right about the limits of national aggregate data.

Conclusion. Reducing out-of-pocket payments from their current 41% of current health expenditure toward the 15-20% benchmark is a necessary condition for Morocco's universal health coverage reforms to translate into measurable child survival gains. As the Groupements Sanitaires Territoriaux are rolled out and AMO-Tadamoun extends legal entitlement to previously uncovered populations, these results expose a persistent tension. Our findings demonstrate that widening formal coverage may not, on its own, improve child health outcomes as long as the out-of-pocket burden remains structurally high. Consequently, achieving financial protection at the point of care is essential for the success of Morocco's universal health coverage reforms.

Keywords: health financing; life expectancy; infant mortality; out-of-pocket payments; universal health coverage; ARDL bounds testing; health outcome selection; Morocco.