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

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).