AMO: Mass Coverage and Structural Deadlock

Compulsory Health Insurance (AMO) in Morocco: Between Mass Coverage and Structural Deadlock

The project to generalize social protection, a cornerstone of the social state envisioned by Morocco, is going through severe turbulence. While the expansion of medical coverage has reached statistical highs, the 2024-2025 report by the Court of Accounts delivers a severe indictment of the model’s viability. Between deep financial imbalances, administrative delays and a weakened public care offer, AMO now stands at a critical turning point.

I. A Mixed Statistical Assessment

The increase in the number of insured people is undeniable, but it conceals persistent pockets of exclusion:

Growth in membership: The number of registered people rose from 26.84 million in 2022 to 31.94 million in 2024, an increase of 19%.
The AMO-Tadamone paradox: This scheme, formerly RAMED, has largely exceeded its targets with 14.47 million beneficiaries, while AMO for self-employed workers (TNS) is capped at 3.5 million, far from the initial target of 11 million.
Those excluded from the system: Despite the efforts, about 13% of the population still has no coverage. Worse, if one looks at active rights, meaning the real ability to access care, 30.4% of Moroccans, or 11 million people remained outside effective protection in 2024.

II. An Alarming Financial Imbalance

The Court of Accounts warns of a drift in expenditure that threatens the system’s sustainability. With the exception of the private-sector employee scheme (CNSS), all other indicators are in the red:

Financial scissors: Between 2022 and 2024, AMO expenditure jumped by 83%, rising from MAD 13.62 billion to MAD 24.95 billion, while resources increased by only 36%.
Deep deficits:
- Public sector (CNOPS): A technical deficit of MAD 1.25 billion at the end of 2024.
- AMO-TNS: A technical deficit of MAD 136 million.
- AMO-Achamil: Liabilities of MAD 425 million.
Depletion of reserves: Without major parametric reforms, the Court expects total depletion of safety reserves by 2030.

III. Gaps in Governance and Collection

The system suffers from a lack of contractual discipline and major institutional delays:

Failure of contribution collection among TNS: The overall collection rate among self-employed workers does not exceed 37%, 46% according to some CNSS sources, but with wide disparities: 22% for farmers compared with 90% for auto-entrepreneurs.
Delays in the reform of public enterprises: The transformation of public health establishments and regulatory agencies, such as ANGSPE, into joint-stock companies is stalling. Of the 17 texts provided for by Framework Law 50-21, only 9 have been published. The legal transformation deadline set for July 2026 appears increasingly untenable.
Persistence of exceptional schemes: The delay in integrating mutual funds and internal funds under Article 114 keeps around 1.25 million employees outside the unified scheme, depriving the system of crucial resources.

IV. A Care Offer Imbalanced in Favor of the Private Sector

AMO massively benefits private clinics because the public hospital remains unattractive:

Capture of expenditure: In 2024, the private sector captured 91% of expenditure on care reimbursed by health insurance. This figure rises to 97% for private-sector employees.
Failure of the public hospital: Despite the reform, the public sector attracts only 9% of AMO financial flows. Medical deserts and obsolete technical platforms push insured people toward the private sector.
High out-of-pocket costs: Social protection still does not protect household finances enough. Average out-of-pocket costs range between 30% and 37%, and peak at 47% for certain chronic diseases, such as diabetic retinopathy, because of an obsolete National Reference Tariff (TNR) that has not been revised for years.

V. Operational Dysfunctions: The Insured Person’s Ordeal

Administrative management is marked by delays that directly affect citizens’ health:

Prior authorizations: The legal 48-hour deadline is systematically exceeded, reaching an average of 124 to 131 hours in 2024 for the public sector.
Reimbursements: Around 3.2 million files for outpatient care experienced payment delays between 2021 and 2024 at CNSS level.

Conclusion and Recommendations

The Court of Accounts report is not a death certificate, but an alarm signal for an urgent transition toward unified management, with the CNOPS transfer to CNSS enacted by Law 54.23.

Our recommendations:

Immediate revision of the TNR: To reduce out-of-pocket costs and align with real care costs.
Implementation of the single manager: Accelerate the merger of funds to achieve economies of scale.
Strengthening public-sector attractiveness: A sine qua non condition for rebalancing expenditure and saving AMO from being siphoned off by the private sector.
Digitalization of contribution collection: Condition certain administrative services on contribution payment for TNS to ensure the fund’s sustainability.

AMO is at a crossroads: either it becomes a true universal safety net, or it collapses under the weight of its own unfunded mass expansion.