Morocco is an Arab country in North Africa. It covers 716,550 square kilometers and has a population of nearly 36 million. The median age is 29.3 years. Morocco’s estimated gross domestic product (GDP) in 2019 was $122 million. As of 2019, Morocco’s health budget was equivalent to 4.5% of the total government expenditure.1-3
Cancer Burden in Morocco
There are about 50,000 new cases of cancer in Morocco each year. Cancer is also responsible for 13.4% of deaths in the country. The most frequent tumor type, regardless of gender, is breast cancer, which represents 20% of cases. Lung cancer ranks second (11.4% of cases), followed by colorectal cancer (6.7% of cases).
The standardized incidence rate of cancer rose from 101.7 per 100,000 Moroccans in 2004 to 137.3 per 100,000 in 2012. The increase in the incidence rate is due to many factors, relating to aging of the population, risky behaviors (eg, tobacco use, poor diet), lifestyle changes (eg, sedentary lifestyle, obesity), as well as improvements in access to cancer diagnosis and organized programs for the early detection of cancer.
Access to Innovative Treatments in Morocco
Since 2005, all Moroccan citizens are required to be members of a basic medical insurance plan, the AMO (Assurance Maladie Obligatoire, or Compulsory Health Insurance). The social protection system covers all employees: workers and retired employees from the public sector benefit via CNOPS (Caisse Nationale des Organismes de Prévoyance Sociale, or National Social Welfare Organizations), and employees and retired workers from the private sector benefit via CNSS (Caisse Nationale de Sécurité Sociale, or National Social Security).
The National Health Insurance Agency (Agence Nationale de l’Assurance Maladie, or ANAM) ensures technical supervision of these social protection systems. ANAM grants reimbursement of many, but not all, innovative cancer medications, despite similar benefits and cost, and the criteria are not always clear. For example, trastuzumab, pertuzumab, and ado-trastuzumab emtansine (T-DM1) are all reimbursed for use in advanced HER2-positive breast cancer, whereas T-DM1 is not reimbursed for use in early disease (but trastuzumab and pertuzumab are).
The poorest and most vulnerable part of the Moroccan population has access to RAMED (Régime d’Assistance Médicale, or Medical Assistance Scheme), which allows persons who are not members of the AMO to benefit from treatment dispensed in public medical centers. However, access to innovative treatments is limited for this population. Oncology costs are escalating beyond RAMED capacities to fund treatment, and these people may need to rely on other organizations.
Since 2005, the Lalla Salma Foundation, a nonprofit organization created through an initiative of Her Royal Highness Princess Lalla Salma, has worked in concert with its partners to implement a national health system dedicated to fighting cancer. The Lalla Salma Foundation collaborates with pharmaceutical companies to enable RAMED patients to access innovative anticancer treatments. Each year, this protocol allows more than 1,500 patients to benefit from therapies mainly for breast and colon cancers. Limited access to medications may also be improved through negotiations between the Ministry of Health and pharmaceutical companies regarding prices, manufacturing of generic medications, and drug donation programs.4
Lack of Research and Publication Activities
Morocco has considerable research and clinical trial potential. However, these endeavors remain challenging and plagued with difficulties, despite the development of various strategies.
Morocco-specific cancer research is crucial for the development of health-care policies in the country. The need for more Morocco-based studies goes hand-in-hand with improving the number of cancer publications in the country.
A PubMed search of scientific publications related to Morocco using the terms cancer, neoplasia, neoplasm, tumor, and oncology showed far fewer results than in Western countries. Although a total of 2,173 such articles were published in Morocco over the past 10 years, there were 381,807 cancer publications in the United States, 360,308 in China, and 110,738 in Germany during the same period. Of note, the yearly number of cancer-related publications focusing on Morocco increased from 105 in 2010 to 340 in 2020. Also, Morocco is ranked among the top African countries in research according to the H-index, which measures the productivity and citation impact of publications by particular scientists or scholars.5
Many factors may explain the low rate of research publications in Morocco. First, there is a lack of access to reliable and valid data. Second, the “research ecosystem” is insufficient, with a lack of biobanks and information systems, and key experts such as data scientists, data managers, and biostatisticians are rare in Morocco. Globally, there are fewer cancer researchers in comparison to Western countries; according to the Cancer Research Institute, the cancer research network includes just 383 cancer researchers from all over the country. Third, many researchers do not have access to research funds for publication fees in open-access journals. Finally, there is no official policy to encourage health research in general; regulation is burdensome, complicated, and not conducive to the initiation of such efforts.
Moreover, national spending on health research and development is relatively modest. In 2010, Morocco invested 0.71% of its GDP on research and development, which was considerably lower than that of the United States (2.73% in the same year). Cancer research funding is an important issue, since Morocco’s health budgets are limited, leading to a dependency on foreign and pharmaceutical company support. In addition to funding opportunities being infrequent, access to them can be complicated and time-consuming.
Types of Cancer Research in Morocco
In addition to the low number of publications, the types of published papers are also insufficient. In this review, we noted a high proportion of case reports (40%), with a scarcity of analytic studies, systematic reviews, and meta-analyses. No more than 0.6% of Moroccan cancer-related publications are clinical trials. Moreover, just 33 current cancer trials are recruiting patients within the country, despite the increasing experience of oncologic investigators in Morocco.
Indeed, there is an urgent need to include patients from Morocco in drug development clinical trials. These high-level studies remain the gold standard for analyzing health-care interventions, especially for cancer treatments in different ethnic populations.
Efforts to Improve Cancer Research in Morocco
Several measures are being established to improve cancer research in Morocco. For example, two regional cancer registries have been set up in the country: the Rabat Cancer Registry and the Grand Casablanca Region Cancer Registry. The latter is based on a population sample accounting for 10% of the Moroccan population, which confers validity to this registry.
The Ministry of Health has set up a National Cancer Prevention and Control Plan (NCPCP) in close partnership with the Lalla Salma Foundation.6 The NCPCP has developed a strategic program for the next decade, including measures to improve research in cancer prevention, early detection, diagnostic and therapeutic management, and palliative care.
In addition, the Ministry of Health is working on facilitating clinical trial administrative paperwork, particularly that needed to obtain approval from the Regional Committee of Protection of People, the National Commission for the Protection of Personal Data, and the Directorate of Medicine and Pharmacy. These streamlined measures will encourage the initiation of multicenter clinical trials in Morocco.
The Cancer Research Institute (Institut de Recherche sur le Cancer, or IRC) is also playing a crucial role in the enhancement of cancer research in the country through eight strategies: (1) setting health research priorities; (2) strengthening health research capacity; (3) defining and implementing norms and standards; (4) developing health research; (5) translating evidence into policy and practice; (6) monitoring and conditioning research; (7) financing research; and (8) evaluating effectiveness in health research.
Since 2016, 38 cancer research projects have been financed by the IRC. The selection of projects is conducted mainly on the basis of their alignment with NCPCP priorities. The IRC encourages researchers to publish by subsidizing publication fees in scientific journals and helps increase the visibility of local research by supporting the PubMed indexing of a Moroccan oncology journal currently being established.
Other ongoing IRC projects include the development of a digital pathology program, a national network of biologic resources (called the Moroccan Biobank), a Moroccan cancer researchers’ network, and participation in information systems and platforms for cancer research such as REDCap (Research Electronic Data Capture).
Furthermore, faculties of medicine all over the country are working on improving efficiency and the capacity to conduct trials through postgraduate certifications launched with foreign collaborative partners. Finally, Moroccan learning societies such as the Moroccan Association for Training and Research in Medical Oncology (Association Marocaine de Formation et de Recherche en Oncologie Médicale, or AMFROM), the Moroccan Society of Cancer (Société Marocaine du Cancer, or SMC), the Moroccan Association of Thoracic Oncology (Association Marocaine d’Oncologie Thoracique, or AMOT), the Moroccan Society of Digestive Oncology (Société Marocaine d’Oncologie Digestive, or SMOD), and the Moroccan Association of Urologic Oncology (Association Marocaine d’Oncologie Urologique, or AMOU) are developing strong research initiatives through collaborations with other learning societies in the Middle East and North Africa as well as with the European Society for Medical Oncology and ASCO.
Dr. Benbrahim is Associate Professor of Medical Oncology in the Departments of Medicine and Pharmacy, Hassan II University of Fez, Morocco, and a member of SMC and AMOT. Dr. Boutayeb is Professor of Medical Oncology, University of Rabat, and a member of the Translational Oncology Research Team (Équipe de Recherche en Oncologie Translationnelle, or EROT). Dr. Errihani is a member of the faculty of Medicine and Pharmacy at Mohammed V University, Rabat, Morocco, and President of both AMFROM and EROT. Dr. Mellas is Professor of Medical Oncology in the Departments of Medicine, Pharmacy, and Oncology, Hassan II University Hospital of Fez, and is President of AMOT.
DISCLOSURE: Dr. Benbrahim has participated in a speakers bureau for MSD Oncology, Novartis, Sanofi, Servier, Amgen, and Roche. Dr. Boutayeb has participated in a speakers bureau for Janssen Oncology, MSD Oncology, Novartis, and Roche; and has been reimbursed for travel, accommodations, or other expenses by Ipsen and Roche. Dr. Errihani has served as a consultant or advisor to AstraZeneca, Janssen Oncology, Merck, MSD, Pfizer, and Roche; has participated in a speakers bureau for Amgen, Astellas Pharma, Novartis, and Servier; has received research funding from Roche; and has been reimbursed for travel, accommodations, or other expenses by Merck and Pierre Fabre. Dr. Mellas has participated in a speakers bureau for MSD Oncology, AstraZeneca, Astellas Pharma, Janssen Oncology, Novartis, Servier, Amgen, and Roche.
REFERENCES
1. Oxford Business Group: Morocco ramps up health care spending to build on recent progress. Available at https://oxfordbusinessgroup.com/overview/invested-care-state-has-ramped-sector-spending-latest-budget-build-gains-made-care-recent-years. Accessed May 12, 2021.
2. Organisation for Economic Co-operation and Development: Gross domestic spending on R&D. Available at https://data.oecd.org/rd/gross-domestic-spending-on-r-d.htm. Accessed May 12, 2021.
3. TheGlobalEconomy.com: Morocco: Research and development expenditure. Available at https://www.theglobaleconomy.com/Morocco/Research_and_development. Accessed May 12, 2021.
4. SJR–SCImago Journal & Country Rank [portal]: Data retrieved from https://www.scimagojr.com/countryrank.php. Accessed May 12, 2021.
5. Foundation Lalla Salma: Cancer research. Available at http://www.contrelecancer.ma/en/recherche-en-cancerologie. Accessed May 12, 2021.
6. Institut de Recherche sur le Cancer: Plan National de Prévention et de Contrôle du Cancer 2020-2029. Available at https://www.irc.ma. Accessed May 12, 2021.
