The Limits of Free Health Care Schemes: the Case of Access to Care for Beneficiaries of the Moroccan Medical Assistance Scheme (RAMed) Suffering From Cancer


 Background: The article discusses the limitations of a free-of-charge scheme for the poor in the case of cancer patients. The literature on free access to hospitals, especially on the African continent, has already mentioned these limits: occasional payments for care and transport. The particularly ambitious Moroccan free-of-charge scheme (RAMEd) presents the same problemsMethods: It is based on a qualitative survey of 120 patients and 30 doctors or nurses with whom we conducted semi-structured interviews over several months.Results: The results show that patients continue to pay for care and medical imaging as well as their transport to the hospital. They pay for care and examinations that are not available at the hospital or wait for them to be available, which is a danger to their chances of survival.Conclusions: The limitation of the RAMed is that it does not cover the cost of transport or the structural deficiencies of the hospital. The result is the paradox of a free service that is costly for patients. We stress that targeted policies cannot replace structural policies and, on their own, do not remedy inequalities, particularly territorial inequalities.

generalization, the RAMed had more than ten million a liated persons, including 6,345,525 with active rights [15]. However, as early as 2014 the public authorities began to worry about the sustainability of the scheme. Evaluations were initiated, including one conducted by the National Observatory of Human Development (ONDH).
Several questions arose. (1) The rst concerned the number of bene ciaries. Initially, it had been planned that they would be divided into non-contributory "poor" and contributory "vulnerable" (with a ceiling of 600 DH per household). The project designers had estimated that 65% would be contributors. After the implementation of RAMed, they represented only 16% of the population covered while, during the same period, the High Commission for Planning (HCP) counted, in 2014, 1,605,000 poor people (in terms of relative poverty). The criteria used to be considered "poor" by the RAMed were thus much more inclusive than those used by the HCP, which seems to be due primarily to the targeting instruments used [16]. This resulted in strong pressure from the demand for free care on a hospital system that was already considered insu ciently equipped at the time of the generalization of RAMed [17]. (2) The second issue was the nancing of the system. None of the nancial modalities planned to support the scheme had been implemented; they still are not [18]. Free care is currently nanced by the ordinary operating budget of hospitals, whereas it was planned that the care provided would be invoiced and the bills paid by the State according to a mechanism to be put in place. (3) The state of the health infrastructure and its capacity to accommodate RAMed bene ciaries. As indicated in the report on the sectoral strategy of the Ministry of Health for the period 2012-2016 [17], the health infrastructure at the time of the launch of RAMed was already insu cient, since at the time when the Moroccan government was beginning to worry about RAMed's sustainability, the share of the State budget devoted to it was 5.6% (2014), whereas the share recommended by the WHO was 9%.

Overall impact on bene ciaries
In addition to these strictly nancial issues, there is also the question of the impact of the scheme on its bene ciaries [19,20,21]. The rst scienti c publications point to a number of problems, this even highlighted by Yates: the continuation of patient payments and the di culties related to their transportation from their places of residence to the care structure. A survey of 186 hemodialysis bene ciaries of RAMed in the Souss-Massa region highlighted these di culties: lack of medical transport and ambulances to take patients from their homes to the hemodialysis center; payment of at least part of the medical analyses, as hemodialysis patients have to resort to private imaging and medical analysis centers to make up for the shortcomings of the public sector. To meet these expenses, patients are forced to go into debt [21]. This pathology-related situation is con rmed, from a general point of view, by a study based on the analysis of 2013 and 2015 data from the Moroccan Household Survey Panel Data (MHSPD) of the National Observatory of Human Development (ONDH). It shows that the expenditures of households bene ting from RAMed are equivalent to those of comparable households not bene ting from RAMed [20]. In other words, the effects of the disease on household impoverishment are equivalent; however, they are not equivalent in terms of the effects on health, since the main part of the care is covered by the RAMed, and from this point of view, populations suffering from serious pathologies have effective access to the care they need (as shown by the case of dialysis patients). The result is that, while the public health objective seems to be substantially being achieved, the objective of combating inequalities is marking time and the overall well-being of patients remains limited.

Method And Approach
The choice of a qualitative approach, involving semi-structured interviews, stems from the fact that it is necessary to enter into the daily life of people in order to evaluate the moral and nancial costs of a care system. At this stage, we cannot operate from above the bene ciaries of the system. This information bias stems from a general tendency, present in the evaluation of public policies, to underestimate the practical and ordinary consequences of these policies [22]. The paradox, as Anne Revillard [23] strongly emphasizes, is that evaluation bypasses the consequences on individuals in order to focus on the performance of public action, yet this performance is only a means to an end; and it is in relation to the end -the impact on the lives of everyone -that a public policy must be evaluated.

Description of the survey
We conducted a qualitative survey using semi-structured interviews, involving patients (N = 120) and health care personnel (N = 30), notably doctors and nurses. We did not distinguish between forms of cancer, as we were interested in the di culties of access for patients. Certainly, di culties or facilities inherent to particular forms of cancer appeared, but this point remains secondary in our survey. A little more than two thirds (68%) of the patients we interviewed came from or resided in rural areas. This was due to the cities we had chosen: Khenifra, the capital of a rural province in the Middle Atlas, Meknes and Fez, which receive patients from the surrounding rural areas, especially Khenifra. This over-representation of rural people was deliberate, since our research focused on identifying and assessing access di culties. In both Khenifra and Meknes, our surveys were conducted with patients from a provincial hospital; in Fez, it was a University Hospital Center (CHU).
Most of the interviews were conducted in situ, in the oncology centers of Meknes and Fez. This allowed us to observe at the same time the daily routine of the care facilities, the arrival of patients, their care, interactions and, sometimes, altercations with the caregivers. The interviews generally lasted between half an hour and an hour. They were conducted either in Moroccan dialect Arabic (Darija) or in French, especially with the doctors and head nurses. The interviews we conducted focused on access to care. To do so, we asked patients to describe the steps they have taken and are taking to remedy their ailments, from the symptoms or incentives (e.g., prevention campaigns) that led them to seek care to the sequence of diagnosis and care. The survey was authorized by the Ethics Committee of the Faculty of Medicine of Fez and supported by the Moroccan Cancer Research Institute (IRC).
In addition, we use, in this article, some interviews conducted at the Hassan II University Hospital Center (CHU) in Fez on the occasion of an between survey conducted in 2015, concerning access to care for RAMed bene ciaries. The more general framework of the care sectors considered allows us to better situate the di culties encountered by cancer patients. This survey was authorized by the Ethics Committee of the Faculty of Medicine of Rabat and nanced by the National Observatory of Human Development (ONDH) as part of an evaluation program of RAMed.

Results Of The Survey
Our survey showed that the initiation of patients' † therapeutic itineraries did not concern the main course of care, generally surgery (if necessary) and chemotherapy, but sometimes radiotherapy, examinations and, more broadly, the phases preceding this main course or following it. Examinations are generally problematic, in the sense that their availability is not guaranteed. These problems are all the more present when dealing with care structures far from the university hospital, as shown in the interview below: "Until now, we have been able to have free chemo sessions, scans and certain analyses, but we have to go elsewhere when the analyses do not exist here. We had problems when she had complications in the brain, these analyses cost 2000 DH ‡ , and they did not exist in the hospital, neither in Sidi Said nor in Mohamed V. So we were obliged to take an appointment here, at the CHU, we had an appointment for one month (...) -So, what are the things that your mother has been paying for all along? -Doctor's fees, biopsy, MRI, ECG, chemo tests, injections at 100 DH, and treatment after chemo.
-And the analyses for the ganglion, did she also pay for them? -Yes, the biopsy at Moulay Ismail Hospital, but the analysis at the private laboratory at 600 DH. » § In addition to these problems of availability of medical services, there are problems of transport, as patients have to travel from their homes to the place of care or examination. Depending on the circumstances, transportation problems also involve accommodation problems, if patients are received as outpatients but cannot be cared for on the day of their arrival. In general, however, patients note the advantages of the RAMed and consider quite unanimously that "without it, [they would] not have been able to be treated". Nevertheless, their journeys are marked by payments and these are linked to de ciencies affecting the place of care to which they belong.

The unavailability of care
The notion of de ciency appears to be important for qualifying the unavailability of care. Under the terms of the law instituting the RAMed, as well as from the point of view of the organization of the health system, not all care and not all examinations are and need to be available in each medical facility. Some require the presence of a category of care or examination, others do not. We considered unavailability to be a de ciency when the care or test was supposed to be available but was not. The interviews conducted with medical and nursing staff were very useful in that they gave us an overview of the care and examinations available and supposed to be available in the various institutions.
In fact, the medical pathways appear to be riddled with de ciencies: "People in Oujda [the respondent lives in Oudja] do the chemotherapy sessions, but when they want to do the radiotherapy, they have to go to the clinic and there they have to have a lot of money.
-And what did you do?
-We came to Fez where they refused to give him radiotherapy and then to Rabat where we were told that radiotherapy was available in Oujda. In Oujda, they gave us a technical form (sic) to get rid of us. When we showed the form to Fez and Rabat, the people in charge of the department told us that we should not come here at all.
-And? -Did we go to a private clinic? -How much did it cost you?
-9000 DH for a session plus 900 DH for the scanner, he needed 3 or 4 sessions.
-So in total?
-And for MRI, -We were given an appointment for two months from now but we did it in private the same day. We gave him a 500 DH injection.
(…) -When she found out she was sick, did she have the RAMed card? -Yes, she already had it.
-So thank God.
-Yes, of course, you know the people who don't have RAMed in Oujda do the same treatments and they pay 600 DH per session; some have to do 30 sessions.
-600 DH the session at the clinic?
-No 600 DH at the public hospital but in a clinic it costs 1500 DH.
(…) -So at rst you paid for the MRI, -Yes 300 DH.
-And the analyses? How much is it?
-The biopsy at 500 DH and the rst analyses at 300 DH.
-So we loaned you the money for the MRI, -Yes... 3000 DH -And to get here? Transportation costs?
-Someone else loaned us the money.
-How many kilometers is that?
-How long does it take? -Three hours by car and ve hours by bus.
-And by train?
-The train is too expensive.
-How much does a round trip cost? -She must always be accompanied because of her health condition.
-Are you the one who always comes with her? -Yes, it's still me and I have to leave my little girl in Oujda.
-This time who came with her? -This time there is his sister and me.
-How much did it cost you? -It is 100 DH the place in bus, that is to say 600 DH for a round trip.
-Were you asked for money (bribery) to get the RAMed card?
-Not at all.
(…) -Has your budget been affected by the disease? -Yes, a lot, when we want to make purchases we give up because we prefer to keep the money for the expenses of the illness.
-And morally? -It has changed our lives.
-When you arrive in Fez at the bus station, how do you get to the hospital? -By cab (20 DH) and also a cab when we want to go from our home to Oujda to the bus station.
-What about fatigue? -Yes, a lot especially since she is sick. » ** This case is quite long. The therapeutic itinerary began with radiotherapy, which was not available in Oujda, where the patient lived, so she moved to Fez and then to Rabat, in order not to have to leave the public system where she bene ted from RAMed coverage of her care. The patient was nally treated in Fez, at the Oncology Center of the University Hospital. She therefore travels from Oujda to Fez for her radiotherapy sessions, covering more than 300 kilometers. This trip is the consequence of a de ciency, since radiotherapy should be available in Oujda. The cost of transport and accommodation is doubled, since the patient is accompanied by her daughter. It should also be noted that the MRI was performed in the private system, in order to avoid the two-month waiting period indicated to the patient. This was due to the large number of people who needed to undergo this examination and the lack of available machines. However, the question of delays does not only concern the examinations. It can be a more global issue for the entire medical care, as shown in the case below. The patient was sent by a clinic to the University Hospital of Fez after it diagnosed a brain cancer requiring surgery that the patient could not handle. He therefore turned to the public system but had to wait several months before he could be operated on. When he was discharged, a CT scan was required, which had to be done in a clinic, again because of the length of the waiting time: "Who gave him this appointment? -University Hospital. It was very far away as an appointment, that's the problem. The appointments are very far away.
-Patients cannot bear to wait for these long periods.
-Yes, so when he was admitted to the hospital, he had surgery last November. He was here for 15 days. When he was discharged, he was asked to have a CT scan, we were given a very distant appointment, so we did it at the clinic. » † † This situation is re ected in all the interviews we conducted. The long waiting times are a direct consequence of the disproportion between the number of people being cared for and the resources available. In general, we found that all patients, at one time or another, had to leave the medical pathway, either for procedures that were covered but unavailable, or for expenses that were not covered, such as medication (other than those provided as part of hospital care) or transportation to get from their home to the hospital facility. At this point, the patient and family are left to fend for themselves, i.e., to take care of the step that cannot be accomplished within the medical pathway. As the interviews show, these situations are painful. First of all, because they involve choosing to pay not to wait or to pay for access to medication. The patient and his or her family are then forced to make a trade-off between the stress felt, the pain or the risk of loss of life chances, on the one hand, and the expenses required for other essential household needs, on the other. This often results in the use of assistance from close family members (children, parents, siblings) and sometimes more distant ones (cousins). However, these auxiliary resources can only be called upon on an ad hoc basis. As for arbitration, when it is negative, i.e. when the patient cannot make a detour through the private sector in order to bene t from examinations or care not available in the public sector, it implies a risk that can be signi cant for him or her, as one nurse explains: "If the patient is developing complications, the examinations allow us to know it, but if we have to wait three months to have the appointment, then carry out the examinations, wait months for a specialized opinion, during this time the pathology evolves and we nd ourselves with situations where, because of this delay, complications appear with irreversible consequences. Nothing can be done. We watch helplessly as the patient's condition deteriorates because he is poor. What are you going to do? » ‡ ‡

The problem of transport
The problem of transportation appears to be considerable, as patients must, in most cases, travel to the cancer center. There are a dozen public centers in a territory comprising 62 provinces and 12 regions, but there are not as many centers as regions. Rabat (the capital) has 3 structures dedicated to oncology. There are 9 for the rest of the territory. Regardless of whether this is su cient, the relatively small number of oncology facilities indicates that some of their patients have to travel to receive care. It should be added that, if certain facilities are de cient, patients have to travel to another oncology center than the one to which they belong, and therefore generally to a more distant center. We have thus noted displacements from Oujda to Rabat, Fez and Meknes and displacements from Meknes to Fez. Distance has direct effects on the duration and cost of travel; these effects are all the more important because they are often accompanied by a family member. The two interviews below describe these di culties: "What do you use for transportation to get to the cancer center?
-A bus at 40 DH one way.
-How long does the trip take? -3 hours.
-Do you go alone or are you accompanied? -My husband always accompanies me.
-How much does it cost you to go there and back? -200 DH approximately, 40 DH multiplied by 4, that is to say 160 DH, but the remainder is for the cabs. In any case, when you bring back a blue ticket [a 200 DH ticket], you get it at the end of the day.
-Since the beginning of your illness, how many times have you traveled for treatment? -I would not know how to answer you, at the beginning I stayed quite often in Meknes, now I move almost every two or three weeks. » § § "Since 5 o'clock in the morning, I am awake, I made the dawn prayer and I came to Meknes from Khenifra. I would have liked to have these treatments in Khenifra without moving, just walking and coming back, but unfortunately I have transportation costs in addition... Once I nish, I return to Khenifra the same day. It costs me 110 DH to make a round trip the same day, not to mention the cabs for 20 DH, in Meknes, plus 14 DH of cab in Khénifra, without forgetting the food. For example, I haven't eaten yet, plus I have to eat light, diet, it's even more expensive! (...) It's not only the fatigue on the physical level, because I'm waiting for the moment when I go home myself, but especially the fatigue of asking your relatives for money that weighs heavily on my conscience and affects my dignity. » *** As can be seen, the problem of transport does not follow on from Thaddeus and Maine's work on the three delays [24], the second delay being that for going from the patient's home to the place of care. In fact, transport is considered in relation to its duration and the urgency of the need for it. Thus, much of the literature on this issue, beginning with Thaddeus and Maine's article, focuses on access to care for childbirth, i.e., the accessibility of care in the event of an emergency. It is not the emergency that prevails in the case of cancer patients. On the other hand, transportation di culties can lead to irregularities in access to care, and these can be cumulative. In interviews with both health care staff and patients, it appeared that a chemotherapy session could be postponed for three weeks (until the next scheduled session) because the patient could not nd or pay for transportation or because the road was not passable (this situation only occurs in winter when there is snow). In some cases, however, the period without care may be longer, when the patient could not nd or pay for transportation ( rst postponement) and then could not leave home because of snow (second postponement). These situations do not appear to be the most numerous, but they do exist. They show that what is at stake in the lack of transport, in the case we are interested in, is not the immediate risk but the long-term risk, the stress and discomfort of the patients as well as their impoverishment. This, however, is not the result of inadequate hospital or RAMed services, but is the result of the lack of a stable, e cient, and robust ambulance and medical transport system in Morocco, and the lack of a system for paying for transport costs. There is therefore not only a problem of access to care, but also a speci c problem of access to ambulances [25]. Patients are thus required to pay for their own travel from their homes to hospitals and oncology centers. † The continuation of the remedies necessary for the treatment of the disease, when they differ from the care pathway provided by the RAMed.

Discussion
What emerges from the eld survey that we conducted is the importance of conversions of medical itineraries into therapeutic itineraries, i.e. situations where the different therapeutic phases do not take place within the same care system, because the latter is incomplete. In other words, the RAMed bene ciaries we surveyed, even though they are included in a free access to care system, are still looking for health resources and are obtaining them at their own expense. The same phenomenon can be found in other situations as indicated in the introduction (see above "Introduction"). These are not isolated cases but all the people we met (N=120). Of course, the payments are of varying importance, but there are always payments: intra-urban and inter-city transport costs, examinations (most often medical imaging), care (radiotherapy, in particular), purchase of medicines, accompaniment costs (for patients who cannot travel alone); and several payments are often combined.

Structural problems
This situation suggests the existence of structural problems, at least two of which seem massive: (1) the organization and management of transport and (2) the availability of the necessary resources in the public system for the completion of the medical pathways for people with cancer. To become aware of these problems, a particular investigation is needed, involving not just looking at the available gures for the increase in hospital care or the continuation of household health expenditure, but at what points in the medical pathway this health expenditure takes place. They could take place upstream of the medical pathway, in a phase of self-medication or independent consultation of private practitioners; they could involve recourse to alternative medicine or result from a voluntary departure from the medical pathway.
On the contrary, what appears to be happening is that patients' expenditures are taking place within the stages of the medical pathway, in order to complete them. In other words, patients subsidize the free treatment they receive. This state of affairs is general and characterizes access to care for RAMed bene ciaries. However, people with cancer are not ordinary bene ciaries since they are supposed to be part of the National Cancer Prevention and Control Plan (2010-2019) or NCCP † † † , launched in 2010. This plan includes ensuring the provision of care for patients at all levels of the public health system, coordinating them and developing the human resources assigned to these different levels. This plan is supported by the Lalla Salma Foundation ‡ ‡ ‡ , wife of King Mohammed VI, whose action is undeniable [26]. However, this plan does not seem to have a signi cant impact on the two types of dysfunction that we have mentioned, because they are not so much the result of shortcomings in oncology as of shortcomings in access to care as a whole. Just as the RAMed, as a free-of-charge system, cannot ensure that the necessary resources are present in the health care system, the PNPCC cannot ensure that these resources, which are lacking in general, are present in particular, except possibly in a one-off manner.
In fact, what emerges here is the di culty of targeted policies. Some resources can only bene t speci c categories if they bene t all categories of the population. This is the case for transport infrastructure, including roads, the education system, and the health system. Roads are not built for one type of user but for all users. Similarly, a health system can only take care of a certain category of patients if it is able to take care of all patients. We do not train oncologists, we train doctors rst. Thus, when we describe the di culties of a certain category of patients by following their therapeutic itineraries, we realize that their di culties are the di culties of other categories of patients. Looking at things more globally, it appears that the free-of-charge system is not able to guarantee access to all the care involved in the medical pathways, because it is dependent on the state of the hospital system, to which it makes no contribution. Initially, it was planned that the bills of the patients bene ting from free care would be paid by the State, which would have helped to support the hospitals according to their activity. As this mechanism was never put in place, hospitals took over the RAMed from their regular resources, which impoverished them [18]. Indeed, RAMed is not exactly a social security system in that it does not pay for care (and medical transport) where and how it is available (in the public or private sector). It only provides free access to a prede ned set of resources (those of the hospital), which it does not help to nance. As a result, cancer patients who are bene ciaries of RAMed nd themselves in di cult human and economic situations, even though they are covered by a free-of-charge system. The implementation of a National Cancer Prevention and Control Plan (2010-2019) does not profoundly change the situation in the short or medium term, even if it contributes to an overall improvement in the long term.

A holistic perspective
This situation should lead us to consider the contribution of free health care systems differently: if they are not linked to efforts to develop the health care system, involving an increase in hospital resources and the existence of real out-of-hospital logistics for access to care, they lead to relatively large payments by patients. The question of infrastructure and resources therefore remains central to access to care, as does the question of the share of the state budget devoted to health. From this point of view, the improvement of the situation of a category of patients -in this case those with cancer -is largely dependent on the overall improvement of the resources of the health system and the overall development of certain services such as medical transport.
Perhaps a transformation of the paradigm that applies to the management of the social sector and more broadly to state interventions in developing countries is needed. For the sake of e ciency, localized and sectoral solutions seem to be preferred by state or international actors. In fact, it is easier to pursue a circumscribed project of excellence than to reform all the ins and outs of a dysfunction. This is notably the logic of action of NGOs. It is thus simpler and more rewarding to constitute "islands of prosperity and excellence" [27] than to improve entire sectors of public action. However, these islands themselves are dependent on the rest of the sectors to which they are interconnected, and some of what they do continues to depend on them. Holistic perspectives, structural actions, are therefore still needed. In this case, it is clear that the creation of the RAMed has improved access to care for cancer patients, but it has not done more for them than it has for other categories of patients. Similarly, the establishment and conduct of a National Cancer Prevention and Control Plan (2010-2019) has not improved their situation with respect to the two major problems we have indicated: the cost to patients of certain unavailable medical procedures and the cost of transportation. In fact, there seem to be only two solutions to this: (1) increase the resources of the hospital system and set up a real system of medicalized transport or (2) compensate the payments of cancer patients by a speci c allowance. This would certainly be a localized but transitory action and above all a compensation and not a public action improvement device. (1) and (2) are complementary. These two solutions are based on two simple principles: the holism of public action (recurrent dysfunctions cannot be resolved without getting to the bottom of things) and the right to compensation when a public service fails to produce the goods it is supposed to produce. The application of these principles has a budgetary cost; their non-application has a human cost. This only underlines an empirical reality which is manifested in other situations of implementation of free access to health care: it is not enough. It depends both on the general conditions of free care delivery, as we have shown, and on the local circumstances of its implementation [28,29]. In other words, free care is always limited and variable in scope. † † † see https://www.sante.gov.ma/Documents/Synthese_PNPCC_2010-1019.pdf ‡ ‡ ‡ https://www.contrelecancer.ma/fr/

Conclusion
Our results underline that the success of free health care is largely dependent on the state of the health infrastructure but also on the transport infrastructure and the development of the territory. This question should be developed by also addressing the effect of distance on cancer diagnosis. A study conducted in Morocco on breast cancer showed that diagnosis and treatment were delayed when patients lived more than 100 km from the place of treatment [30]. This shows that free care is far from su cient to compensate for territorial inequalities. In fact, it leaves them unchanged. Of course, it increases access to care but inequalities in access remain. In other words, the ght against health inequalities cannot be limited to the implementation of free hospital care. Paradoxically, this can increase inequalities, insofar as those who can afford the transport and care or medical imaging that is lacking in the hospital bene t more. This situation creates a great disarray among the bene ciaries.
From a methodological point of view, it seems that the survey by semi-structured interviews is better able to show the importance of this disarray, by showing the place it occupies in the lives of patients and their families. It is not a secondary problem in relation to care. On the contrary, it is about the possibility to bene t from care. When the free care system is not su cient, the quality of life of patients is directly affected.

Declarations Ethical Approval and Consent to participate
The study was validated by the Ethics Committee of the Faculty of Medicine of Fez

Consent for publication
The authors agree to the publication of the article Availability of supporting data These are qualitative interviews, several of which are being used for another publication. The data is under embargo until this publication has been published. Thereafter, the interviews will be conditionally available.