Over the last few decades, Morocco has made considerable progress in reducing maternal, neonatal, and child mortality rates and improving key maternal and child health and nutrition indicators. However, important gaps remain between rural and urban areas.
In rural areas, maternal mortality rates are two and a half times higher than in urban areas (111 versus 45 deaths per 100,000 live births). Similarly, infant mortality is 37 percent higher in rural areas: 26 deaths per thousand live births in rural areas versus 19 in urban areas.1
"We still need many things so that all women, whether from the village or the surrounding area, have dignity and give birth in very good conditions," said Najate Nadifi, President of the Riaaya Association for Women's and Children's Health. Nadifi is also in charge of the Community Maternity Facilities (Dar Al Oumouma - reception, accommodation, and sensitization for pregnant women or women who have just given birth and their newborns) in Oulad Ougad, a village that is about a two-hour drive from Marrakech.
"We no longer want any difference between the douar (village in Moroccan Darija) and the city; we want the same services," said Hanae Afrouh, Community Health Worker in Oulad Ougad.
While access to essential maternal and child health services has improved considerably in Morocco over the last few decades, it remains low in rural areas. Almost all women in urban areas – 96 percent - give birth in a health facility, compared with 73.4 percent in rural areas. The stunting rate for children under 5 is 20.5 percent in rural areas compared to 10.4 percent in urban areas. The lack of proximity to health centers and geographical obstacles can explain these access problems. "As we know, there are challenges, mainly geographical obstacles," said Nadifi. "We can lose many pregnant women just because of the delays."
A NEW COMMUNITY HEALTH MODEL IN RURAL AREAS: A THREE-WAY APPROACH
In this context, the National Initiative for Human Development (INDH), the Ministry of Health and Social Protection, and UNICEF piloted a new Community Health Model in 2022 to help improve maternal and child health and nutrition in rural areas. The pilot program has been deployed in three priority regions (Beni Mellal-Khenifra, Draa-Tafilalet, and Marrakech-Safi), covering 14 provinces and 56 rural health centers.
This new program is unique in that it relies on the coordination of three actors, simultaneously involving Rural Health Centers, “Dar Al Oumouma”, and the community health workers.
The health centers welcome women once they are ready to give birth and assist them with childbirth and post-delivery maternal and childcare. Dar Al Oumouma (House of Maternity in Arabic) refers to community maternity facilities in rural areas that support pregnant women and offer them a safe place to stay before and after childbirth.
"Dar Al Oumouma" is a center, for all women, who can come even before birth," explained Nadifi. "They can spend time here while they wait to give birth, in total safety."
Community health workers are mobilized voluntarily and forge a powerful bond between the community and the health system. They engage with pregnant women of the douar, raising awareness about the importance of medical prenatal care.
"The process of caring for pregnant women begins before delivery: the pregnant woman undergoes prenatal consultations. Community health workers are informed that the woman must attend at least four prenatal consultations," said Nadifi. "They contact the nurse who cares for the pregnant woman and is in charge of the pregnancy and childbirth monitoring program."
The community health workers are local residents in the villages, who are chosen and trusted by the community. They provide continuous support throughout a woman’s pregnancy, guiding her until the delivery of her child at the health center, and connecting her to Dar Al Oumouma when needed.
"I no longer deliver women at home. Now, I take them to Dar Al Oumouma," said Rachida Fethi, former traditional midwife and now a health worker, "I tell them if they’re having contractions, they can knock on my door night and day, and if there's anything, they must go to the hospital. Go for a check-up and check for diabetes and blood pressure."
Since 2022, around 1,000 community health workers have been recruited and trained across the pilot’s three priority regions.
"My job is to be in touch with the people of the douar who cannot come to the hospital. Through the training I have undergone, I’ve been given means to keep in touch with people, and I go to their houses for follow-ups," said Afrouh. "There were inevitably obstacles at the start. At first, people didn't accept us. They said, what you're telling us isn't true, we give birth at home," said Afrouh. "We've slowly started to talk, raise awareness, get together, and ask."
Today, in its pilot phase, this community health program has reached around 285,000 beneficiaries (women and children, between January 2023 and December 2024) who have been referred to maternal and child health and nutrition services.
SUPPORTING MOROCCO’S EFFORTS FOR BETTER MATERNAL AND CHILD HEALTH AND NUTRITION
Following the encouraging results of the pilot phase, the National Initiative for Human Development (INDH), in coordination with the Ministry of Health and Social Protection, and with technical support from the World Bank, has developed a scaling-up strategy following an in-depth diagnosis of the pilot phase.
This strategy includes a detailed action plan to strengthen the Community Health Model's programmatic model and performance management system by integrating automated data collection and analysis tools, enabling faster, better-informed decision-making. The strategy also addresses governance and sustainability, adopting a gradual scale-up approach with a prioritization based on human development indicators.
"We have fewer mortality problems, especially for children; we had fetal deaths, we had a lot of problems. Thanks to this community health model, we've taken the problem in its entirety, and we were able to manage given the situation. The impact is obvious, and the quality of care has changed significantly," said Nadifi. "Community health workers have a very important role to play, and sincerely, we would like to see this project expanding to all the localities linked to this village."
