Raja Kassab

Introduction:

The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”[1]. Health is one of human beings’ basic rights as stated in a number of universal charters. The constitution of the WHO, for example, states that the “enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” The same applies to Article 25 of the Universal Charter of Human Rights and Article 12 of the International Covenant on Economic Social and Cultural Rights. These charters also include additional health guarantees for minorities and marginalized communities. However, the fact that rights pertaining to health are stressed in such charters does not correspond to their actual implementation on the ground. In fact, there is a discrepancy between different countries across the world regarding healthcare policies and funds allocated to the health sector. In 2005, WHO member states pledged to develop their healthcare funding policies to achieve full coverage.

This paper focuses on three main points: first, healthcare funding policies; second, healthcare models from different countries to shed light on successful experiences; and third, the ways through which successful models can be used as a guide towards designing better health policies for guaranteeing the achievement of the right to health for all as stated in international charters.

First: Healthcare-funding policies:

Funding health services is directly related to healthcare policies implemented in a given country and it is through these policies that the funds allocated to the health sector are distributed.

According to WHO, funding is the main guarantee for the establishment of a welfare system. Funding in this case does not only mean the accumulation of resources, but also providing the population with fair access to healthcare services without going through financial trouble.

I-   Healthcare services funding sources:

Sources of funding for healthcare services differ from one system to another for in some systems funding might come from one source while in others it can come from multiple sources. Healthcare sources of funding can be divided into three main sections: public, private, and external. Healthcare systems can also be funded through insurance.

1-  Public healthcare funding:

The state takes part in funding healthcare services in all health systems, but this contribution differs from one system to another.

2-  Private healthcare funding:

There are two main types of private healthcare funding:

–      Funding by private or public corporations through the establishment of healthcare centers for the purpose of making healthcare services more accessible and to control funds that were previously managed by other entities such as insurance companies

–      Funding through payments made by citizens in return for healthcare services they receive. Such payments come from the citizens’ own money and is quite hard to calculate accurately especially in developing countries.

3-  External funding sources:

Developing countries face a lot of obstacles in funding their healthcare services, which drives them to resort to other countries to fund their healthcare programs whether through donations or loans. Several bilateral agencies help those countries to develop their funding strategies in order to achieve full coverage. 

4-  Insurance:

This funding source is found in most healthcare systems and is divided into two types:

–      Non-profit insurance systems such as social security

–      For-profit insurance systems such as private insurance companies

Insurance can be voluntary or mandatory upon, for example, taking a job in a particular company. It is also possible to combine voluntary and mandatory insurance as part of supplementary insurance.

II-Funding models for healthcare services:

There are four main funding models in healthcare services:

1-  Voluntary sickness insurance:

Citizens can choose to be part of a social security fund or get insurance at a private company. This model can be found in most Third World countries as well as in a number of developed countries such as Switzerland and the United States.

2-  Mandatory sickness insurance:

Citizens are obliged to join the social security fund and instalments are paid by the employer or the employee and at times each pays a percentage. This model is found in a large number of Western countries such as Germany, Austria, and the Netherlands and some developing countries such as Morocco.

3-  Full insurance:

This is a type of mandatory insurance in which installments are paid by members of the social security fund and others affiliated funds, mainly employees at the public and private sectors and independent workers. What distinguishes this type of insurance from mandatory sickness insurance is the fact that it gives all citizens the right to benefit from healthcare services whether they subscribe or not, which means it also covers the unemployed, senior, and low-income citizens. This insurance is found in European countries such as Sweden and Norway and Arab countries such as Algeria.

4-  Insurance as part of national healthcare service:

This type differs from full insurance in that the state is the only source of funding and is the healthcare provider. All citizens benefit from this kind of insurance and is basically found in Cuba.

Second: Healthcare systems

A healthcare system is comprised of the organizations, resources, and activities that aim at achieving the main health goals based on a set of basic principles such as equal access to services, fair distribution of resources, and integration between sectors.[2] Sickness insurance and medical treatment are the main pillars of this system.

I-   The development of healthcare systems:

In the late 19th century and following the changes that accompanied the Industrial Revolution, injury at the workplace led to rising cases of death and disability. Added to that was the damage incurred by epidemics and various contagious diseases. Such casualties had a negative impact on the production process, which drove employers to provide workers with healthcare services.

Workers’ health became a political issue in several European countries at the same time. In Germany, Bismarck took several measures to win workers to his side and strip socialist movements of their leverage. To do so, he placed health insurance funds under state control, hence depriving unions of one of their major sources of funding[3]. In 1883, he issued a law that obliged employers to provide healthcare for their low-income workers, then it extended to more segments. This was the first type of social security to be imposed by the state. The popularity of this law led to issuing several ones in Belgium in 1894, Norway in 1909, and the United Kingdom in 1911. Following the Russian Revolution in 1917, the state issued a decree that provides all citizens with free healthcare. This became the first central healthcare system to be managed by the state and it lasted for almost 80 years. During World War Two, the Emergency Hospital Service was established in the United Kingdom to treat injured soldiers and paved the way for the establishment of the National Health Service in 1948.

The 1942 Beveridge Report identified healthcare as one of the main requirements for the establishment of a sustainable social security system[4]. The British government stressed in 1944 white paper that citizens need to have equal access to healthcare services, which have to be advanced, comprehensive, and efficient. New Zealand was the first country to authorize the National Health System in 1938. After World War Two, Japan, Chile, and several European countries extended healthcare coverage to include the entire population.

Healthcare systems currently rely, with varying degrees, on one or more of the major models that were developed and upgraded starting the late 19th century.

II-Healthcare models:

Healthcare systems differ according to healthcare models and sources of funding as well as the extent of state involvement in providing healthcare services. However, healthcare systems are generally evaluated based on their ability to provide health services for all segments of a given society regardless of their economic and social conditions and without risking their impoverishment.

1-  Healthcare system in Britain:

The National Health Service (NHS) was established in 1948 based on the principle that “good healthcare should be available to all.” NHS is run by the state, which owns and manages a large portion of the hospitals operating under this system[5]. The same system is found in countries with British influence such as Australia, New Zealand, and South Africa.

1. Healthcare coverage:

NHS is funded by public taxes and run by state institutions. Services are free for citizens provided that they are registered in the system. Patients in this system pay a percentage of the cost of some services such as dental, ophthalmology, and medication prescribed by NHS doctors[6].  In order to avoid waiting lines and to get supplementary services, several employers started resorting to private healthcare companies such as the non-profit BUPA, which was one of the most prominent health insurance companies before the implementation of the state-run NHS.

1. Medical treatment:

The public sector:

The public sector is comprised of hospitals and clinics where both specialists and general practitioners work in addition to nursing, para-medical, and administrative staff. The total number of people who work in health institutions affiliated to the public sector is estimated at more than 1.6 million. The relationship between doctors and the NHS differs based on whether they are specialists or general practitioners.

Around 80% of general practitioners work in NHS affiliated clinics where citizens get healthcare services free of charge provided that they are registered with their respective doctors. With the exception of rural areas, clinics are generally developing into medical centers[7]. Specialists, on the other hand, work in hospitals and patients have to be referred to them by a general practitioner.

The private sector:

Doctors in the United Kingdom have the right to open their own private clinics, where they can work outside NHS hours if they are registered in this system in the first place. Patients who go to private clinics pay both doctor fees and medication.

2-  Healthcare system in France:

Healthcare system in France is a combination of the Bismarck and Beveridge models, which can also be found in several Latin American countries even though medical treatment systems and funding sources might differ.

1. Healthcare coverage:

Health insurance in France goes back to 1930. It started as mandatory insurance for all employees then expanded in 1967 to include all citizens. This shift led to the emergence of several systems[8]. The French healthcare system depends for funding on social security and supplementary insurance as well as the direct contributions of individuals and families. The system is run by the Sickness Insurance Fund, which managed to extend its coverage to 100% of the population and 70% of the cost of health services[9]. Registration in the French system is done in accordance with each citizen’s work and both employer and employee pay the insurance costs. Healthcare services offered by the French system are not totally free of charge as patients pay a percentage known as “ticket modérateur.”

1. Medical treatment:

The medical treatment structure in France includes public health institutions that are categorized under the Public Treatment Service, which in addition to treatment and prevention is engaged in other activities such as education and medical research. There are also for-profit and non-profit private healthcare institutions[10].

The treatment system includes medical centers that were previously called “local hospitals.” These are facilities that offer basic medical services as well as surgery and child labor. Several of those facilities are affiliated to French universities and include a wide range of specializations and patients can go to them directly or after been referred by a local facility.

3-  Healthcare system in the United states: 

1. Healthcare coverage:

Health insurance in the United States is mainly offered by private companies and is usually done through employers. The state offers limited health insurance for senior citizens and the impoverished.

–      Private health insurance:

The percentage of health insurance costs was estimated at 16% of the gross domestic product in 2016, which is the largest in the world and is two and a half times the cost in other high-income countries. Healthcare services in the United States are mainly provided by private and voluntary insurance offered by employers and it covers around two thirds of American citizens. The services offered differ from one company to another, but usually bigger companies offer better coverage[11].

–      Public health insurance:

The public health insurance system in the United States mainly provides service to senior citizens and the impoverished. It is divided into two systems:

• Medicare: It is national insurance program for 65 plus and disabled citizens. It provides mandatory insurance funded by payroll tax and supplementary insurance funded by the state and the contribution of subscribers. It is run by the federal government.
• Medicaid: It is an insurance program that covers low-income families and individuals as identified by each state. That is why coverage differs from one state to another[12].

Several segments of the American population remain, however, without coverage because they cannot afford to pay private companies and are at the same time not eligible for the two available national programs because they do not meet the requirements. The national program implemented by former president Barack Obama, known as Obama Care, aimed at solving this problem. However, it is expected to be annulled by current president Donald Trump.

1. Medical treatment:

Medical treatment in the United States is mainly organized in a set of integrated networks. Private companies attempt to emulate international systems such as the French one particularly in the field of managed care.

• Managed care organizations: This is the most common model in the United States and is comprised of care networks that were established to reduce the cost of healthcare services and that combine insurance with care. These organizations are based on partnership between funders and service providers, which helps in cost cutting. Members are encouraged to go to designated doctors and facilities and patients have to be referred to specialists by family doctors[13].
• Managed care: This system focuses on preventive care and disease management, the latter for the support and follow-up of long-term conditions, serious illnesses, or diseases that involve costly treatment.[14]

4-  Healthcare system in Cuba:

1. Healthcare coverage:

Healthcare is a basic right for all citizens in Cuba and the government works on implementing this principle on the ground through providing health services free of charge to the entire population and through the attention it gives to prevention, primary care, accessibility, and the active engagement of the public in the decision-making process in the health sector. Despite the embargo and subsequent economic problems, this policy led to a remarkable rise in Cuba’s basic health indicators. This was especially shown in the fact that life expectancy in Cuba was estimated at 72.5 compared to 71.9 in the United States. Cuba also managed to eradicate several diseases such as polio, tuberculosis, typhoid, and diphtheria.

The Cuban healthcare system went through several stages for it was for-profit before the revolution, but after 1959 it became a national program run by the state and providing healthcare service to all citizens free of charge. The fall of the Soviet Union and the subsequent tightening of US embargo in the 1990s triggered a major economic crisis. This had a negative impact on healthcare services and threatened its very existence and the availability of medical equipment by 70%. However, health indicators remained stable, which is mainly attributed to the fact the government kept healthcare as one its topmost priorities.

Despite the shortage of resources, the Cuban healthcare system was success because of the government’s political and financial support for bio-technology and epidemiology even in the worst of economic conditions. In fact, the Cuban government spent around one billion US dollars in research and development in the past 20 years. The Cuban bio-technology industry owns around 1,200 international patents and sells pharmaceuticals and vaccines in more than 50 countries. Cuban scientists and researchers also made remarkable progress in the diagnosis, prevention, and treatment of cancer. In 2008, for example, the Cuban Ministry of Health got the patent for the first vaccine for advanced lung cancer and which was discovered at the Center of Molecular Immunity in Havana. The center got the patent for another vaccine for the same type of cancer in early 2013.[15] Cuba was also the first country in the world to receive a validation from the World Health Organization for eradicating the mother-to-child transmission of syphilis and HIV[16].

The Cuban health system was not confined to primary care and scientific research, but its progress was supported by advancement of medical and para-medical education, training, and public awareness. Cuba is known to be the world’s leading country in patients-per-doctor ratio with 6.7 doctors per 1,000 patients, hence surpassing developed countries. Doctors in Cuba are also known to be of the highest caliber.

1. Medical treatment:

Starting from the 1970s and 1980s, the Cuban government turned the healthcare system from a treatment program to a primary care one that starts from local communities. This system is divided into three levels of care:[17]

• The first level is comprised of clinics with family doctors and nurses that deal with common diseases. Because it focuses on prevention, several diseases can be cured or avoided at this level. This level enabled doctors to collect data on diseases and the health conditions of residents in their respective communities, which helped in statistics[18].
• The second level is comprised of hospitals that treat diseases which cannot be treated in the first level.
• The third level is comprised of national health institutes and hospitals that are more specialized than the ones in the second level. In these facilities, more advanced procedures take place such as organ transplants and research is conducted on contagious and tropical diseases.

In the beginning of the 21st century, Cuba embarked on a series of reforms in the healthcare system, the most significant of which was upgrading and redistributing outpatient clinics so that services can be accessible for all citizens[19].

5-  Healthcare system in Morocco:

When Morocco joined the Millennium Development Goals (MDG), it became committed to the eight goals of which the declaration is comprised. It was also committed in 2005 with member states of the WHO to extend healthcare coverage to the entire population, which was stressed in the protocol signed by both the WHO and the Moroccan government in 2017. The 2011 Moroccan constitution stated that healthcare is a basic right for all citizens. However, according to Article 31 “the State, the public establishments and the territorial collectivities” are in charge of making this right accessible to all citizens on equal basis.[20] In 2011 the Economic, Social, and Environmental Council stressed in its Social Charter than physical and mental health is a basic right for all citizens.[21]

1. Healthcare coverage:

• Mandatory sickness insurance ((Assurance Maladie Obligatoire – AMO):

In 2005, the Moroccan government established a mandatory insurance program for the employers and retirees of both the public and private sectors and is expected to extend its coverage to the entire population. This program is run by the National Fund for the Organization of Social Reserves (Caisse nationale des organismes de prévoyance sociale- CNOPS), which handles the employees and retirees of the public sector, and the National Fund for Social Security (Caisse nationale de sécurité sociale- CNSS), which handles the employees and retirees of the private sector. The source of funding for this program is the contributions of employers and employees.

• Medical assistance program (Régime d’Assistance Médicale- RAMED): This system, which is funded by the state, is based on the principles of social support and national solidarity and targets low-income and impoverished citizens who do not benefit from the mandatory sickness insurance. This system was implemented following protests staged in 2012 across Morocco under the leadership of the February 20 Movement.
• Students’ insurance: This system was implemented as of the academic year 2015-2016.
• Supplementary sickness insurance: Employees at the public and private sector benefit from this type of insurance through cooperatives or public (social works organizations) or private insurance companies.
• Independent mandatory sickness insurance: Since state-funded insurance programs cover only 60% of the populations, citizens resort to private companies if they can afford it. This leaves a large segment of the population uninsured. A number of independent professionals have for decades struggled to design and fund an insurance program that covers these segments. In June 2017, the Moroccan parliament approved draft law number 98.15, according to which this program is to be established. According to this program, independent professionals and workers can get insurance. The government is yet to issue a set of laws that regulate this program and determine the way it will apply to each group/profession according to its respective characteristics.

1. Medical treatment:

The medical treatment system in Morocco is comprised of three main sectors: public sector, for-profit private sector, and non-profit private sector[22]:

• Public sector:

The public medical treatment sector is hierarchical with urban and rural healthcare centers at the first level and from there patients can be referred to other more specialized facilities. In addition to treatment, these centers offer preventive care and health awareness. The next level is comprised of hospitals and medical centers as well as university affiliated facilities. In 2011, the Ministry of Health issued the framework law (loi-cadre) on the healthcare and medical treatment system. This law was supposed to set the framework based on which the healthcare[23] system operates so that it can bridge the gap as stated by the minister of health in defense of the privatization of hospital and medical centers. However, this law faced a number of obstacles upon implementation since it was only applied to the public sector[24].

It is noteworthy that health services in public hospitals are not free of charge and are subject to a tariff determined by the Ministry of Health based on the type of service. This tariff is used by the hospitals in accordance with the self-management policies they adopted following the structural reforms imposed by international financial institutions in the mid- 1980s.

• For-profit private sector:

The for-profit private sector has been rapidly developing as a result of the policies adopted in the past few decades and which led to the privatization of a large number of hospitals and clinics and reduced the amounts allocated to healthcare in the public budget. This sector includes 50% of Moroccan doctors, 90% of pharmacists and dental surgeons, and 10% of para-medical professionals. The for-profit private sector grew particularly in large residential areas and medium-size cities at the expense of the public sector after the state’s role in healthcare started gradually shifting into that of a regulator rather than funder and administrator. This was particularly demonstrated in the remarkable decline in human resources and medical equipment as well as the infrastructure of facilities in the public sector, which in turn leads to the deterioration of the services provided. The framework law on the healthcare and medical treatment system also promotes this approach through allowing the selling of public medical facilities to the private sector under the Public-Private Partnership (PPP) where a contract is signed between a private company and a state-owned entity so that the first can provide services for or manage the second. The authorization of the medical assistance system (RAMED) increased demand on public medical facilities, hence increasing the pressure on them and affecting the quality of services.

• Non-profit private sector:

This sector is comprised of clinics and medical centers that are run by National Fund for the Organization of Social Reserves (Caisse nationale des organismes de prévoyance sociale- CNOPS) and the National Fund for Social Security (Caisse nationale de sécurité sociale- CNSS). There are many national associations and organizations that offer healthcare services in a variety of specializations, but they are not equally distributed across the country and there are discrepancies between them as far as human and financial resources are concerned.

The legislative and organizational framework that regulates the healthcare system does not take into consideration the contribution of cooperatives in the field of healthcare service across the nation[25]. For example, the approval of draft cooperatives law (code de la mutualité) in its current form might result in the closure of several of those organizations. Medical cooperatives in Morocco are basically dental clinics, opticians, and specialized labs, but they are facing a lot of obstacles. Private for-profit sector is lobbying for their closure because of the way they affect its businesses in the market. This is done through pushing for the adoption of Article 144 of the second chapter of the Cooperatives Law which is currently being discussed in the parliament.

6-  Healthcare system in Egypt:

1. Healthcare coverage:

The 2014 Egyptian constitution states that healthcare is a basic right for all citizens, yet no laws have yet been issued to implement this on the ground. Mandatory health insurance, funded by employers and employees, currently covers only 52% of Egyptians despite the major role it plays in the third level of healthcare services, which is specialized treatment. This means that 48% of Egyptian people pay for medical services from their own money or are funded by the state. The Egyptian healthcare system is comprised of different programs in addition to a private system[26]:

• Social health insurance: authorized in 1964
• Health insurance for employees at state institutions: 1975
• Health insurance for students: 1992
• Health care for children: 1997
• Private insurance: offered by private companies and is voluntary

1. Medical treatment:

The medical treatment system in Egypt is comprised of three main levels:

• First level: This level is comprised of primary care facilities in both urban and rural areas. Those are divided into health bureaus (329), neighborhood clinics (90), childhood and motherhood medical centers (149), family care units (359 in urban areas and 4245 in rural areas)[27]. These facilities offer primary care services, public awareness especially in family planning and reproductive health, treatment for common diseases, and vaccinations for children[28]. Such facilities offer services for 5,000 citizens.
• Second level: This level is comprised of central hospitals that offer both outpatient and inpatient medical services. Patients can be referred to these hospitals by medical facilities in the first level according to administrative divisions. There is a total of 250 central hospitals across the country.
• Third level: This level of comprised of public hospitals, health insurance hospitals, university-affiliated hospitals, hospitals affiliated to the Ministry of Health, trade unions, and different state institutions such as the police, the army among others. It also includes private hospitals.

The healthcare sector in Egypt suffers from several drawbacks such as the remarkable discrepancy between the number of public and private medical facilities and the number of patients they accommodate as well as the significant decline in the number of public hospitals. The public sector still, however, ranks first as far as the employing doctors and nurses and providing medical services are concerned[29].

Medical facilities are also not equally distributed among different parts of the country and the discrepancy becomes more noticeable upon comparing urban with rural areas. Some governorates are, in fact, provided with more medical services than their population requires. For example, Cairo accounts for 11% of Egypt’s population and gets 22% of its medical services and Alexandria is 5.4% of the population and gets 8.8% of hospital beds while Dakahliya had 7% of the population and gets 6.1% of hospital beds. The same applies to urban and rural areas for while residents of rural areas constituted 57.5% of the population in 2005, their share of hospital beds did not exceed 7.3%[30].

Third: Lessons and alternatives:

A comparison between systems in different countries according to the basic indicators authorized by relevant international organizations, on top of which is the WHO, proves that the success of a healthcare program is not only associated with the amounts spent even though it is an important factor, but also the policies adopted and the accessibility of medical services. According to a World Bank report in 2014, the United States ranked first in healthcare spending by 17.1% of the total gross domestic product followed by Switzerland (11.7%), France (11.5%), Cuba (11.1%), and the United Kingdom (9.1%) while Morocco spends only 5.9% and Egypt 5.6%[31]. As for personal spending on medical services, Cuba comes last (4.4%) followed by France (6.3%), the United Kingdom (9.7%), and the United States (11%) while Egypt reaches 55.7% and Morocco 58.4%.[32]

Regarding accessibility to medical services and the range of healthcare coverage, Cuba comes first (100%), followed by France and the United Kingdom while the United States comes last as coverage does not exceed 25% of the population and does not cover all medical conditions. In Egypt, coverage does not exceed 52% and in Morocco 60%.

Successful healthcare systems are those that offer full coverage for citizens without burdening them financially. That is why the Cuban, French, and British systems are considered amongst the world’s most successful. The common factor between these three systems is that they all utilize the risk sharing approach. This is done through collecting money in advance and administering it in a way that enables each individual in the community of finding the proper funds in the case of illness as if the entire community shares the risk of contracting such illness.[33]

Risk sharing in healthcare can be managed in two ways:

–      Tax-based healthcare system (Cuba and the United Kingdom): The government utilizes tax money to fund healthcare services. This means that all citizens can benefit from these services.

–      Social healthcare insurance (France): Funding for healthcare is obtained from employers, employees, corporations, and the state. The money is placed in social health insurance funds that can take the form of cooperatives. Full coverage cannot be achieved through this system unless all citizens pay their share and this share is determined based on each citizen’s income. The government pays the share of citizens who are unable to contribute at all.

In order to solve problems related to healthcare systems, especially ones pertaining to accessibility of services, it is necessary to increase the amounts allocated in the budget for medical facilities and equipment. As for developing countries, the government can impose higher taxes on certain unhealthy items such as cigarettes, fizzy drinks, and foodstuffs that are high in salt and sugar.

Considering medical treatment, the Cuban and British models focus on several factors that guarantee cost-saving services without compromising the quality of those services. Those factors are as follows:

–      Prioritizing primary and preventive care

–      Relying on hierarchical medical facilities that are accessible to citizens in order for prompt prevention and treatment

–      Appointing family doctors throughout the country to monitor illnesses and collect data on the heath conditions of citizens in their respective regions as well as to make sure that patients are only referred to specialists when necessary

–      Establishing efficient medical, para-medical, and administrative entities

–      Investing in scientific research

It is important to note the drawbacks of the privatization of the health sector and the commodification of health services, mainly the result of the conditions imposed by international financial institutions and which prioritize profit over the quality of services. This is related to a prevalent idea that the public sector is not productive, which is an argument that needs to be refuted mainly through pumping human and financial resources into public facilities. It is also impossible to separate between healthcare and social conditions since health services are amongst the main pillars of equality and social justice. In fact primary and preventive care play a major role in economic and social development since they are part of the basic rights of citizens such as the right to nutrition, shelter, potable water, and a healthy environment.

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[1] Constitution of WHO: principles: http://www.who.int/about/mission/en/

[2] Decree No. 1.11.83 of 2 July 2011 implementing law No. 34.09 on the health system and treatment.

[3] A.J.P. Taylor. Bismarck: The Man and the Statesman. London: Penguin, 1995: 204.

[4] Social insurance and allied services. Report by Sir William Beveridge. Londres, HMSO, 1942. In « le rapport de la santé dans le monde 2000.

[5] Charles Phelps. Les fondements de l’économie de la santé. Paris: Union Editions, 1995.

[6] “Le National Health Service et le système de santé:Origines et fonctionnement du National Health Service.”

http://angleterre.org.uk/civi/sante-health.htm.

[7]Ibid.

[8] Nasr al-Din Eissawi. “Cost Monitoring in Hospitals: The Case of el-Bir Hospital in Constantine [Arabic].” Université des Frères Mentouri Constantine, 2004-2005.

[9] Ibid.

[10]Emeline Laurent. “Organisation du système de santé français.” 2013: https://santepublique.med.univ-tours.fr/wp-content/uploads/2016/07/130308_organisation_sante_EL.pdf

[11] “Groupement d’intérêts publics santé et protection sociale” (GIP SPSI). États-Unis, Paris : GIP SPSI, 2009: https://www.cairn.info/revue-pratiques-et-organisation-des-soins-2009-4-page-309.

[12] Ibid.

[13] “Rédaction de familydoctor.org. Health Insurance: Understanding Your Health Plan’s Rules.” Chicago (USA): American Academy of Family Physicians; 2006. [http://familydoctor.org/online/famdocen/home/healthy/health-ins/734.printerview.html] https://www.cairn.info/revue-pratiques-et-organisation-des-soins-2009-4-page-309.

[14] “Bras P, Duhamel G, Grass E. Améliorer la prise en charge des malades chroniques: les enseignements des expériences étrangères de ‘Disease management’”. Paris: La documentation française; 2006. In https://www.cairn.info/revue-pratiques-et-organisation-des-soins-2009-4-page-309.

[15] Healthcare and Education in Cuba:https://www.internations.org/cuba-expats/guide/life-in-cuba-

[16]WHO in Healthcare and Education in Cuba. https://www.internations.org/cuba-expats/guide/life-in-cuba-

[17] Cuba: les avantages d’un système public de soins de santé. Tous ensemble pour la Santé. https://m3m.be/blog/cuba-les-avantages-dun-syst%C3%A8me-public-de-soins-de-sant%C3%A9

[18] Cuba’s health care policy: prevention and active community participation: Iatridis DS. https://www.ncbi.nlm.nih.gov/pubmed.

[19]Ahmed al-Deeb. Rose al-Youssef Magazine: http://www.rosaelyoussef.com/article/22053

[20] Constitution of the Kingdom of Morocco. Chapter Two, Chapter 31 The Government Secretariat, July 2011.

[21] The Economic, Social, and Environmental Council. “Towards a New Social Charter: Goals and criteria [Arabic],” January 2012, pp. 26-27.

[22] “Basic Healthcare Services [Arabic].” The Economic, Social, and Environmental Council, law no. 4/2013: www.cese.ma

[23]Decree number 1.11.83 issued on July 11, 2011 to implement framework law number 34.09 on the healthcare system

[24]Decree number 2.14.562 issued on July 24, 2015 to implement framework law number 34.09 on the healthcare system. Official Gazette, issue no. 6388, August 20, 2015.

[25]Law number 65.00 on Basic Medical Coverageis the main one under which the healthcare system in Morocco is regulated.

[26] Yehia Tamouh. “Medical Insurance Law: A Critical and Technical Analysis [Arabic].” Medical Insurance and Reform Policies in Egypt. Proceedings of the seminar held by the Health and Environment Development Association in cooperation with Center for the Studies of Developing Countries, 2008. Pp. 21-28.

[27]Central Agency for Mobilization and Statistics, 2014.

[28] Nagwa Khallaf. “Report on Medical Services in Egypt [Arabic].” The Health and Environmental Development Association, Cairo 2005, p.57

[29]“Healthcare Services between Public and Private Sectors [Arabic].” Central Agency for Mobilization and Statistics, 2010.

[30] Elhamy Merghani. “Report on Economic Trends [Arabic].” Al-Ahram Center for Political and Strategic Studies, 2010.

[31] Dépenses en santé, total (% du PIB).Base de données sur les Comptes nationaux de la santé de l’Organisation Mondiale de la Santé: apps.who.int/nha/database.

[32]The International Bank for Reconstruction and Development (1998- 2014).

[33]OMS. Rapport sur la santé dans le monde. Le financement des systèmes de santé. Le chemin vers une couverture universelle. 2010.