Access to healthcare among Moroccan Breast Cancer Patients: experience of the National Institute of Oncology in Rabat

Fahd Elkhalloufi1*, Saber Boutayeb 1,2, Youssef Lamrani Alaoui3, Anass Nmari 4, Hassan Errihani 1,2

1Mohammed V University, Faculty of Medicine and Pharmacy, Rabat, Morocco.
2National Institute of Oncology, Department of Medical Oncology, Rabat, Morocco.
3Mohammed V University, Rabat, Morocco. Mohammadia School of engineering.
4Hassan II University, Casablanca, Morocco. Dept of American Studies

*Corresponding author

*Fahd Elkhalloufi, Mohammed V University, Faculty of Medicine and Pharmacy, Rabat, Morocco, Av Mohamed Belarbi El Alaoui B.P 6203 Rabat Institute.


Background: Moroccan cancer patients suffer from poverty, unemployment, illiteracy, and insufficient medical coverage. With an inescapable impact on the healthcare team and therapeutic care, cancer remains a costly disease that leads to the inevitable impoverishment of Moroccan patients. Despite all the efforts made by the Moroccan government to ensure a better quality of access to healthcare. The main objective of this study is to explore socio-cultural and economic challenges to access healthcare for cancer patients at the National Institute of Oncology in Rabat.

Materials and Methods: 380 participants were included in this study. It takes place between December 2020 and May 2022 at NIO. The Patients included are a convenience sample with histologically confirmed cancer. Cases with cerebral metastasis or lacking capacity were excluded. Participants were assessed prospectively using a questionnaire covering socio-cultural and economic characteristics. The statistical significance was tested using the Chi-square test. A p-value of was considered statistically significant.

Results and conclusions: Poverty, unemployment, illiteracy, lack of social security medical coverage, transportation, distance, and use of traditional medicine are the main hindrances cancer patients suffer from, with an unavoidable impact on the healthcare and therapeutic care teams. Cancer remains a costly disease that leads to the inevitable impoverishment of Moroccan cancer patients.

Keywords: Access to healthcare, breast cancer, socio-economic barriers.


In 2020, Morocco recorded more than 59,370 new cases of cancer. Breast cancer is the most frequent type (11,747 cases), which represents 38.9% of female cancers (1). In Morocco, access to health care, which is a universal right, is blocked by a multitude of challenges (2). Moroccan cancer patients suffer from poverty, unemployment, illiteracy, lack of social security, and inadequate health insurance. Cancer remains a costly disease that leads to the inevitable impoverishment of Moroccan patients (3). Despite all the efforts made by the Moroccan government to ensure a better quality of access to care (4). In terms of culture, breast cancer is synonymous to death (5). Illiteracy and spoken Amazigh language have an impact on the understanding of cancer diagnosis and its therapeutics. They influence the adaptation to a medical environment with its codes, rites, language difference, and the occurrence of conflicts with the care teams (misunderstandings, non-respect of the difference, collusion).

The purpose of this study is to examine the sociocultural and economic challenges to accessing healthcare for breast cancer patients.

Materials and method

The purpose of this study is to explore the impact of sociocultural and economic barriers to access healthcare for breast cancer patients. The data about the selected cases take place between December 2020 and May 2022 at NIO prospectively and exhaustively. The descriptive study was approved by the ethics committee of the Faculty of Medicine and Pharmacy of the flap under N° 11/20. Patients included were those with a histologically confirmed cancer, independent of stage, treated and followed-up in the NIO. All patients were adults of 20-90 years, aware of their illness, and they all gave informed consent for enrolment in the study. Cases with a diagnosis of diffuse cerebral metastasis or without mental capacity were excluded.

The statistical significance was tested using the Chi-square test. A p-value of was considered statistically significant.

For data collection, a questionnaire with questions adapted to the main socio-cultural and economic characteristics of Morocco: Age, gender, marital status, number of children, spoken language, ethnic group, education, professional situation and monthly income, social security, residence was opted for. The following are the socio-economic barriers taken into consideration: illiteracy, Language, Transportation, distance, income, and Insurance. Sociocultural barriers included: visits of marabouts, use of medical plants, treatment by traditional healers, and Ruqya.


Three hundred eighty (380) breast cancer patients were interviewed in this study.

Table 1: Socio-demographic characteristics of participants

Regarding the table 1, the median age of the participants was 49 years. 67.9% of the participants are married patients, whereas 10.8% are divorced, 87% of whom have been divorced due to their cancer. The population is made up of an ethnic melting pot of Arabs and Amazighs with percentages of 82.1% and 17.9% respectively. 91.6% of the participants speak Arabic, and 8.4% speaks purely Amazigh. 47.6% of the patients come from rural areas.

Table 2: Medical characteristics

Table 2 summarizes the medical characteristics. 24,5% of the patients have metastatic cancer. 83.9% of the participants are undergoing chemotherapy. 44,7% of the patients are using traditional medicine.

Table 3: Socio-Economic characteristics

Table 3 illustrates the socio-economic characteristics. 61.3% of the participants are illiterate patients. 76.6% are unemployed. 23.4% of the participants have a job of which 69% are in the informal sector. Regarding the patients’ monthly income, 81.3% have no income. 18,7% have an income below the SMIG (guaranteed inter-professional minimum wage) which is 270$ /month. Regarding medical coverage, 77.1% of the participants have no insurance. In the same, 92.9% of the participants consider that the cost of cancer care exceeds their financial capacity, with monthly material expenses that varies from 300$ to 500$ in 57.7% of the population studied. 62.9% mentioned the high cost of radiological and biological examinations. To access care, patients followed at NIO travel distances ranging from 5 km to 1200 km with a median of 118 km. 68.7% of the participants come from land-locked areas with geographic barriers. This constitutes an additional charge for the patient (transportation costs, accommodation). 85.3% report the high cost of transportation to reach NIO which is more than 50 $ on average. Finally, 92.9% of the participants considered cancer a costly disease.

Table 4: Sociocultural characteristics

According to the results obtained, 5.3% of the patients resort to the visit of the marabouts as a complementary treatment for cancer. 36.3% use Roqya as a cancer treatment. 86.6% of the participants are the practitioner’s prayer. 30.5% consider cancer as a divine punishment 47.4% of patients use medical plants and 36,3% use the Ruqya.


Based on the findings, unemployment, low income, lack of insurance, and illiteracy are the major socio-economic challenges cancer patients face. Numerous studies show that unfavorable economic conditions of patients are at the forefront of access to healthcare. Errihani et al. (2010) reported that poverty among Moroccan cancer patients, especially those consulting a public institution, is the main handicap suffered from (3). Fang et al. (2013) demonstrated that cancer patients retain less employment. Which constitutes a barrier to accessing care (6). In addition, cancer patients report more job discrimination or rearrangement of the work post obstacle to return to work (7). Moreover, the patients employed in the private and informal sectors attribute the loss of their income more to their illness, which constitutes a barrier to access to healthcare (8).

Regarding monthly income, 76.6% of the participants have no income. Numerous studies mentioned that low patients’ income status could create several barriers to accessing healthcare. These intersecting barriers can include accommodation (9), transportation (10), and medication (11). Low patient income and the cost of the treatment are far beyond the financial capacity of most patients. The high cost of treatment can contribute to the impoverishment of households, and lead to a cycle of "catastrophic expenditure" (12).

Regarding social security, 66.2% of the participants have no insurance and benefit from free health care only within the limits of the services offered by NIO. However, this system suffers from several difficulties (13). While in the case of the expedition of RAMEDs validity, they are obliged to pay for all health care services. This adds a heavy additional burden to the overall management of the disease and inequalities in access to care (14). In the context of low social security, patients are more exposed to discrimination in access to cancer care (15). Patients who are members of health insurance also claim the high cost of oncology healthcare (16).

Regarding gender barriers, women occupy a lower rank than men in the social scale (17). The illiteracy rate was four times higher among women than men (18). Thus, making it difficult to access care and adapt to the disease. Illiterate women are often financially dependent on their husbands who pay for the costs of the disease. This goes in line with the low rates of working women among the participants. This social and economic vulnerability results in greater suffering and distress for female cancer patients compared to male patients (3). This is illustrated by the number of patients who are divorced after being diagnosed with cancer.

Concerning geographic barriers. Anderson et al. (2006) show that the geographic barriers related to the lack of resources and infrastructure contribute to hindering the early detection and treatment of cancer (19). In this research, 47,6% of the participants live in rural areas. According to O'Dowd et al. (2012), patients from rural areas are less likely to access care (20). Rural areas are characterized by a shortage of general practitioners and specialists. This can impact treatment adherence, care access, and quality of life (21).

Another barrier to healthcare resides in illiteracy and speaking purely the Amazigh language. Errihani et al. (2010) demonstrated that illiteracy and the Amazigh dialect generate not only anxiety for the patients, but also for the physician, who must ensure therapeutic care alone without the patient being involved (3). Poor communication in the medical encounter can result in an incomplete or inaccurate history, misdiagnosis, a treatment plan based on misinformation, and poor understanding from the part of the patient of his condition and the prescribed treatment (22).

Concerning sociocultural barriers, a huge rate of participants is moving towards the use of traditional medicine (medical plants 47.4%, the use of Ruqya 36.3%). Cancer patients use medicinal plants to increase their chances of treating cancer (23). Traditional treatments are accessible, affordable and culturally acceptable (24).The accessibility of the majority of these treatments makes them all the more attractive when healthcare costs are exploding and austerity is almost worldwide. In a study on the use of medicinal plants in oncology, 35% of the cancer patients surveyed among 1234 used plants, of which 98.5% did not reveal the information to their attending physician (25). Moreover, 16% of these patients are exposed to more or less serious consequences (acute pyelonephritis, functional renal failure, diarrhea, vomiting, constipation, rectal bleeding, and consciousness disorders) (26). Gruénais et al. (2018) found that one of the reasons for the non-use of medical care frequently mentioned is the preference given to traditional practices. Another challenge to healthcare access is the choice of  “Roqya” on the account of medical treatment. This new spiritual therapy, adopted by some patients, is based on the recitation of Koranic verses and invocations taught by the Prophet Mohamed (27). The patient can treat himself or herself or with the help of a roqya (Raqi) therapist. Its users believe that it is effective in the treatment of incurable diseases like cancer. For the Raqis, when certain symptoms persist after patients have consulted an oncologist, who uses modern medicine, they deduce that the evil eye is responsible for the illness. But the most serious is when some patients abandon their treatments, convinced that their ailments can be treated with Roqya (28).


After a thorough analysis of the barriers discussed above, it is clearly deduced that cancer is a costly disease that can lead to the impoverishment of Moroccan patients. Cancer is a disease that affects different spheres of the patient's life: personal, conjugal, familial, and professional life. Upgrading social security coverage and optimizing medical coverage for oncology patients can contribute to better access and better quality of care. It is important to take the results of this study into account in the therapeutic management of patients to ensure comprehensive care.


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