The Challenges of Active Recruitment Policies for the Moroccan Healthcare System

I spent last year in Morocco studying Arabic and while I was there, I became interested in the healthcare system. I heard a lot of anecdotes of people taking German classes in order to move to Germany, specifically to work as nurses. This got me thinking about the migration of healthcare workers, and the effect that active recruitment has on developing countries such as Morocco.  In recent years the Moroccan healthcare system has undergone many changes, new policies and funding systems have been implemented with the aim to improve overall access to healthcare and the health of Moroccans. There is a focus on those disproportionately affected by health challenges such as living in rural areas and being vulnerable to poverty due to low income. Additionally, Morocco must balance maintaining its healthcare workforce while competing with higher paying opportunities available in countries such as Germany. It is important to consider the severity of the obstacles that are currently facing Morocco’s healthcare system, in order to understand the impact caused by active recruitment of healthcare professionals from Germany and other European countries.

The issues that all Moroccans face in relation to healthcare disproportionately affect those living in rural areas. In 2006 only 16% of Moroccans were covered by health insurance – with this rate being even lower in rural areas (Boutayeb, A. 2006). Additionally, access to healthcare is affected by the quality of infrastructure. The disparity between urban and rural areas was highlighted most recently in 2023 when the Marrakech-Safi earthquake devastated numerous rural towns as well as damaging parts of the historic Medina in Marrakech. The city was not as badly affected as the surrounding towns partly due to its distance from the epicentre but also due to the fact that most buildings in the centre met modern building standards, which is not the case for the buildings in the affected settlements like the town of Tafeghaghte (Rafferty, J.P. 2023). The areas most affected by the earthquake were located in the hills where the roads are considered poor quality. The earthquake rendered many of the roads impassable during the critical period when many were in need of relief and aid. This undoubtedly contributed to the number of fatalities; reportedly even up to 5 days after the earthquake some survivors had still not been reached with the necessary relief supplies such as food, water and tents (Rafferty, J.P. 2023).

The Moroccan government was criticised for its handling of the situation after the earthquake, adding to the claims that poor governance is an issue that still needs to be addressed within the Moroccan health care system (Mahdaoui, M. and Kissani, N. 2023).

Furthermore, there is a lack of healthcare professionals working in rural areas, with over 80% of them practising in cities, despite the fact that the majority of the population resides in rural areas (Zahouani, C. et al. 2022). Arguably this is due to the fact that rural areas in Morocco are not attractive in terms of professional development.

This phenomenon is exacerbated in rural areas, where there is a lower proportion of healthcare professionals. There remains a significant unreliability in the delivery of medications, as well as a lack of technical equipment, both of which compromise the quality of medical care that can be delivered (Zahouani, C. 2022). As a training or newly qualified doctor, the concept of treating patients without the appropriate equipment or medicine is unappealing and would likely lead to most cases from rural centres being transferred to urban centres. Furthermore, many Moroccan doctors choose to specialise, potentially due to the higher wages, and this training must take place in the properly-equipped and educational urban centres. Overall, the working conditions in rural centres are poor due to the existing lack of staff, appropriate equipment, medicines and facilities. Poverty in these areas (Boutayeb, A. 2006) may contribute to increased rates of disease meaning that doctors in rural centres will face bigger challenges in regards to treating patients and professional development. These factors mean young doctors are unlikely to choose these areas as their place of work.

In addition, many Moroccan healthcare professionals complete their training in Morocco, free of charge, only then to migrate abroad (Zbiri, S. 2024), particularly to Europe, in order to obtain a higher salary (Idrissi, B.I. et al. 2023). According to the Statista Research Department (2024), there was 7.2 doctors per 10,000 people in Morocco in 2019 compared to the average of 2.9 doctors per 1,000 people as calculated by the BMA (British Medical Association, 2021). The efforts of the Moroccan government to improve these ratios risk being thwarted by the emigration of qualified doctors and nurses.

Germany has previously been criticised for its active recruitment of healthcare workers, particularly from across the Balkans. Health officials in countries such as Bosnia have expressed concerns that there would be a severe lack of trained medical staff in the near future (Reuters, 2017). According to the Agency for Labour and Employment, in 2016, 10,000 Bosnians applied for work permits in Germany. According to Reuters, nurses at this time were paid between 250-400 euros per month in Bosnia and Serbia, compared to a starting salary of 1,500 euros in Germany. This wage gap begins to explain the number of healthcare professionals who responded to Germany’s 2016 call for foreign workers. Germany aimed to fill gaps in its labour markets by adjusting the visa process for foreign workers.

Despite criticism, Germany has continued to adapt its policy in order to facilitate the registration of international health workers. The skilled worker immigration law Fachkräfteeinwanderungsgesetz approved in July 2023 allows international workers fitting certain criteria to travel to Germany in search of work. This law makes it easier for those with experience or a degree in a skilled profession to settle in Germany (International Health Policies, 2023). Nurses and those with some nursing experiences are able to search for employment in Germany. Germany voluntarily adheres to the WHO Global Code of Practise on the International Recruitment of Health Personnel, which aims to ensure the strengthening of health systems by discouraging the recruitment of health workers from the 57 ‘red-listed countries’. Therefore, when German government officials visited Ghana, one of the red-listed countries, certain news agencies speculated that they were considering healthcare recruitment from Ghana. Germany is not the only country that has to be mindful of recruitment from red listed countries. In 2023 the independent Migration Advisory Committee (MAC) released its annual report stating that roughly 35% of doctors and 20% of nurses recruited to the UK are from ‘red list’ countries such as Bangladesh, Pakistan, Nigeria, Zimbabwe, and Ghana. The report stated it is possible that ‘social media algorithms’ are encouraging workers from red listed countries to migrate to the UK.

There is a lack of statistical data and few studies addressing the issue of Moroccan healthcare workers emigrating to Europe. It is apparent that there are many national causes that motivate healthcare professionals from low- and middle-income countries, such as Morocco, to relocate to European countries like Germany. While Morocco has made policy changes that stipulate that qualified health professionals must stay in Morocco to work for a set period past qualifying, it is still experiencing high levels of emigration of healthcare professionals (Sylla, A. et al.). Morocco is not on the WHO ‘red-list’ which emphasis even further the impact that active recruitment has on all countries, even those not considered high risk. These observations highlight the importance of ethical recruitment in all cases and adherence to the WHO code. The question for Morocco, like many other developing countries, is how to balance the right of an individual to move freely and the needs of the national healthcare system in which they are investing.