Free health care for the poor: a good way to achieve universal health coverage? Evidence from Morocco

Policies and programs aimed at giving access to health care free of charge for some segments of the population are increasingly being put in place by low- and middle income countries, going against the Washington-consensus era recommendation to impose user fees on public health care to insure a better quality of service. Yet, such policies may not be suited for middle-income countries, where user fees are not necessarily be the biggest barriers to health care. We study a nationwide example of such a policy with the generalization of the Medical Assistance Regime or RAMED in the Kingdom of Morocco, a policy aiming at giving free access to hospital care to the poorest quarter of the population. Using nationally representative panel data collected before, during and after the extension of the policy, we show that the removal of user fees did have a positive impact on access to health care, but that this impact comes mostly from poorer, rural households. We also study the impact on health expenditures, and find that it has not led to a decrease of the financial burden, except for the subset of urban households that have recurring health expenditures. Overall, our result show that in a middle income country , user fees, even modest, seem to significantly deter healthcare usage for the rural part of the population.