Morocco, a New Era of Robotic Surgery

Robotic surgery has been widely adopted over the past two decades, because it offers significant advantages such as minimally invasive access, precision, ergonomic design, and enhanced safety. Today, it has become the gold standard in numerous countries for various surgical procedures. In the United States and England, for instance, more than 75% of radical prostatectomies are now performed with robotic assistance [1].

However, introducing robotic surgery into healthcare systems in low- and middle-income countries, presents a unique set of challenges.

While the procurement of medical equipment typically follows a standard contractual process, the integration of robotic surgery into a healthcare system extends far beyond the mere acquisition of a robotic device. First, beyond the multi-million-dollar price of the equipment itself, systems need to consider the ongoing cost for maintenance and consumables, which add a further $3000 to $5000 to each procedure [2].

Embracing robotic surgery involves complex economic and logistical challenges, as well as scientific considerations, and institutions and healthcare systems need robust policies to protect the purchase of medical equipment. In low-resource countries, it may be difficult to sustain the viability of robotic surgery. Pakistan’s robotic surgery program, for example, has faced repeated collapses due to financial constraints [3]. Frequent assessment of the costs and benefits of the program are essential.

Another critical issue is the creation of a sustainable patient recruitment network. Studies have shown that increasing the volume of surgeries can reduce the overall cost of a robotic surgery program, with the break-even point being calculated at a minimum of 349 procedures per year [4]. Moreover, the economic justification for robotic surgery becomes more significant in complex cases compared with simpler procedures [5]. Therefore, implementing robotic surgery necessitates a comprehensive vision and the establishment of an adequate health landscape.

Training surgeons in robotic techniques is another demanding aspect that requires significant time and effort, and it should be integrated into a validated educational curriculum. Transitioning to robotic surgery presents a steep learning curve, even for surgeons experienced in laparoscopy [6]. In urology, for instance, robotic-assisted radical prostatectomy is a particularly challenging procedure. Beyond the relatively simple learning curve depicting operative time and blood loss, achieving proficiency in oncological and functional outcomes is more complex and less predictable [7]. Various training protocols have been employed, including proctoring, fellowships, and 3D simulation programs.

Morocco has recognized the importance of acquiring surgical robots, both to reduce the disparity with Europe, given its geographical proximity, and to enhance its image as an economic leader in Africa. Morocco has made significant strides in health policy, as evidenced by a more than 50% increase between 2015 and 2021 in the health sector budget, which now accounts for 7.1% of the total state budget [8].

The ambitious initiative to upgrade the health system has focused on three priorities:

• The first is to expand medical training by increasing both the quantity and the quality of medical education. This includes the construction of new university teaching hospitals, with eight currently in operation. The plan is to build one university teaching hospital in each of Morocco’s 12 counties. Ultimately, the goal is to increase the number of medical school graduates (including doctors, pharmacists, and dentists) from the current 2092 to 8770 by 2030 [9].
• The second is to enhance the private sector. In fact, an amendment of laws governing the practice of medicine has resulted in expansion of the private healthcare sector, which now accounts for one-third of the country’s hospital bed capacity.
• The last is to expand social security and insurance coverage. Currently, 70% of the population has medical coverage, which is largely due to a major compulsory health insurance project that costs over MAD 14 billion annually. Governmental organizations provide coverage for 79% of the insured population, while private insurance covers only 21% [8].

Morocco has already installed two surgical robots: a Revo-I robot at the teaching hospital in Agadir and a Tumai robot at a private hospital in Casablanca. The country is also preparing to acquire eight more robots for use in military, public, and private healthcare facilities, with urology, visceral surgery, gynecology, and thoracic surgery being the primary specialties involved. The procurement of robotic equipment is funded by both public and private sources.

Despite these advancements, Morocco’s robotic surgery program is still in its infancy. Specific legislation and reimbursement protocols are under discussion and will likely take several months to finalize. The goal is to establish a fair financing system that makes new technologies accessible to less affluent communities. It is important to note that the current classification of medical procedures in Morocco does not yet include robotic surgery, and the few procedures that have been performed so far have been patient-funded. The private sector relies on experienced Moroccan surgeons practicing in Europe to advance their projects, while military and public institutions may engage in proctoring experiences and training abroad [10].

The gradual implementation of robotic surgery in Morocco holds great promise, though its viability and profitability remain a challenge for a middle-income country.