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© 2023 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

SIUJ  •  Volume 4, Number 3  •  May 2023 SIUJ.ORG

Key Words Competing Interests Article Information

Urology, Morocco, health, developing 
countries

None declared. Received on March 17, 2023 
Accepted on April 5, 2023

Soc Int Urol J.2023;4(3):162–163

DOI: 10.48083/ WJRO7072

162

UROLOGY AROUND THE WORLD

Trends Towards Sub-Specialization in Urology:  
What About Morocco?

Jihad El Anzaoui,1 Abdelghani Ammani,1 Jalal Eddine El Ammari,2  My Hassan Farih2

1 University Sidi Mohamed Ben Abdellah, Faculty of Medicine in Fes, Urology Department; Military Hospital My Ismail Meknes, Morocco  
2 University Sidi Mohamed Ben Abdellah, Faculty of Medicine in Fes, Urology Department; Hassan II Hospital, Fes, Morocco

The tremendous expansion of medical knowledge has created challenges for learners and practitioners. Sub-
specialization, defined here as a limitation of practice to a confined and sophisticated niche of the whole specialty, 
has created experts who have delved into new fields of research and have presented new perspectives and new 
discoveries[1]. In the most developed countries, sub-specialization is becoming a standard of practice. Elsewhere, 
however, limited resources make sub-specialization unaffordable, particularly in countries that are still struggling to 
achieve basic medical coverage for their populations. Morocco is a developing country that has made great economic 
and social progress in recent decades. The health system has been revised in its social and economic aspects by the 
introduction and expansion of compulsory health insurance and the stimulation of private investment. Productivity 
and profitability are defined as the new foundation.

Sub-specialization, as indicator of quality is, to our knowledge, rare in the Moroccan context. In contrast to certain 
specialties that have been oriented towards sub-specialization, such as paediatrics and cardiology, the general practice 
remains dominant in the urology field, few urologists pursue a sub-specialized practice in Morocco, and their influ-
ence is certainly limited. The main obstacle is the limited number of urologists. According to official statistics, there 
were 351 urologists in Morocco in 2019 for 35.5 million inhabitants, that is 0.9 urologists per 100 000 inhabitants[2]. 
This figure is low compared with developed countries such as the United States, with 3.22 urologists per 100 000 
inhabitants[3] or France, with 2.06 per 100 000 inhabitants[4]—and even compared with other specialties in Morocco.

The low number of urologists in Morocco makes the issue of sub-specialization secondary to the establishment  
of adequate health coverage in the peripheral areas. However, a rapid increase in the number of urologists, thanks 
to the greater number of university teaching hospitals (currently 8), is improving medical coverage in the under- 
medicalized zones. The objective is to increase the yearly number of medical school graduates from the current 2092 
to 6530 in 2025[5].

On the educational level, the fellowship system for post-graduate sub-specialized training is predominant in 
English-speaking and Commonwealth countries. Morocco, however, follows the French system in which post-grad-
uate education is based on university diplomas. While the fellowship training relies on a well-structured clinical and 
research path inside clinical departments, the Moroccan system is based mainly on theoretical courses supported by 
less structured practical and research training.

Furthermore, Moroccan universities do not offer a great choice of diplomas— in either number or area  
of coverage[6].

At the institutional level, although the university teaching hospital departments are currently well 
endowed with medical equipment, the orientation towards sub-specialized practices remains an individ-
ual decision rather than being dictated by a care policy. Urology in particular is a dynamic and rich specialty.  

http://SIUJ.org
mailto:jihad.elanzaoui%40usmba.ac.ma?subject=SIUJ


The lack of sub-specialization in high-volume centres 
such as university teaching hospitals delays the learn-
ing curve and produces surgeons who lack the skills for 
some complex and time-demanding procedures. To find 
an equilibrium between “minor” surgical interventions, 
which are numerous and will consume operating room 
time, and “major” interventions, which bring prestige to 
the department, is challenging.

In some countries, the organization of the health 
system requires a level of quality matching with a high 
level of sub-specialized practice. In France, for instance, 
the creation of national network for authorized centres 
to deal with rare cancers implies a highly specialized 
practice in these centres[7]. In the same country, the 
practice of oncological surgery is framed by a threshold 
of a minimal number of yearly cases[8]. This measure 
highlights the link between quality of care and level 
of expertise. In the Moroccan context, however, it is 
widely recognized that maintaining a highly special-
ized practice in the private sector is not a great advan-
tage in view of the scarcity of private urologists: 167 in 

References

1. Ficarra V, Mirone V, Dasgupta P. Urologists of tomorrow – the case for 
educational intervention. BJU Int.2016. doi:10.1111/bju.13732

2. Royaume du Maroc haut-commissariat au plan (2019). Les indicateurs 
sociaux du Maroc. Available at: https://www.hcp.ma/file/231203/. 
Accessed April 20, 2023.

3. American Urological Association (2019) The State of Urology 
Workforce and Practice in the United States. Linthicum, Maryland, 
U.S.A. Available at: https://www.AUAnet.org/common/pdf/research/
census/State-Urology-Workforce-Practice-US.pdf. Accessed April 
20, 2023.

4. Ministère des Solidarités et de la Santé. Direction de la recherche, 
des études, de l’évaluation et des statistiques. Démographie des 
professionnels de santé. Available at: https://drees.shinyapps.io/
demographie-ps/. Accessed April 20, 2023.

5. Comment le gouvernement compte tripler le nombre des lauréats 
de médecine. Le Matin.ma. February 24, 2022. Available at: https://
lematin.ma/express/2022/gouvernement-compte-tripler-nombre 
medecins/372519.html. Accessed April 20, 2023.

6.  El Anzaoui J, Ammani A. State of art of neuro-urology in the Moroccan 
context. Arab J Urol.2021;20(2):105 –106. doi:10.1080/209059
8X.2021.2007465

7. Institut national du cancer (INCa) (2015) Réseaux nationaux 
pour cancers rares de l’adulte, appui à la decision. Available at:  
https://www.e-cancer.fr/content/download/118020/1407522/file/
Resaux-nationaux-cancers-rares-adultes-2015.pdf. Accessed April 
20, 2023.

8. Or der of M ar ch 2 9, 2 0 0 7 s e t ting t he minimum annual 
ac tivit y t hr esholds applic able to c ancer t r e at ment c ar e 
activity. NOR: SANH0721406A JORF n°76 of March 30, 2007 
Text n° 68. Available at: https://www.legifrance.gouv.fr/jorf/article_
jo/JORFARTI000001885113. Accessed April 20, 2023.

9. Maroc-Carte sanitaire 2019 : les derniers indicateurs chiffrés du 
secteur. October 1, 2019. Available at: http://2m.ma/fr/news/
c ar t e - s anit air e -2 019 -le c ar t- en t r e -le - p ublic - e t-le - p r i v e - s e -
creuse-20191001/. Accessed April 20, 2023.

10. Arrêté du ministre de la santé n° 177-06 du 26 hija 1426 (27 janvier 2006) 
fixant la nomenclature générale des actes professionnels. Available 
at: https://w w w.sante.gov.ma/Reglementation/Nomenclature/
Documents/Arrêté n° 177-06.pdf. Accessed April 20, 2023.

2019[9]. Additionally, in Morocco, the pricing system 
of the social security bodies does not accept the excess 
fees imposed by sub-specialized expertise, creating an 
implicit disincentive[10]. For these reasons, it is difficult 
to abandon general urology practice in the private sector 
in favour of a sub-specialized practice.

Considering the accelerated development of medi-
cal knowledge in different fields, the evolution towards 
surgical excellence will certainly impose the expansion 
of sub-specialization in the near future. The creation of 
referral centres able to promote the level of local training 
and produce local guidelines, particularly in cancer and 
infectious diseases, is needed. Making Morocco a leader 
in its African environment and an exporter of medical 
knowledge is perhaps only feasible through a restoration 
of the entire health care system towards sub-specialty 
training in coming years.

Acknowledgments
The authors would like to thank Mme Fiqhi Zahra and 
Mme Smahane Doukkali for their technical support.

163SIUJ.ORG SIUJ  •  Volume 4, Number 3  •  May 2023

Trends Towards Sub-Specialization in Urology: What About Morocco?

https://www.hcp.ma/file/231203/
https://drees.shinyapps.io/demographie-ps/
https://drees.shinyapps.io/demographie-ps/
https://lematin.ma/express/2022/gouvernement-compte-tripler-nombre%20medecins/372519.html
https://lematin.ma/express/2022/gouvernement-compte-tripler-nombre%20medecins/372519.html
https://lematin.ma/express/2022/gouvernement-compte-tripler-nombre%20medecins/372519.html
https://www.e-cancer.fr/content/download/118020/1407522/file/Resaux-nationaux-cancers-rares-adultes-2015.pdf
https://www.e-cancer.fr/content/download/118020/1407522/file/Resaux-nationaux-cancers-rares-adultes-2015.pdf
https://www.legifrance.gouv.fr/jorf/article_jo/JORFARTI000001885113
https://www.legifrance.gouv.fr/jorf/article_jo/JORFARTI000001885113
http://2m.ma/fr/news/carte-sanitaire-2019-lecart-entre-le-public-et-le-prive-se-creuse-20191001/
http://2m.ma/fr/news/carte-sanitaire-2019-lecart-entre-le-public-et-le-prive-se-creuse-20191001/
http://2m.ma/fr/news/carte-sanitaire-2019-lecart-entre-le-public-et-le-prive-se-creuse-20191001/
https://www.sante.gov.ma/Reglementation/Nomenclature/Documents/Arr%C3%AAt%C3%A9%20n%C2%B0%20177-06.pdf
https://www.sante.gov.ma/Reglementation/Nomenclature/Documents/Arr%C3%AAt%C3%A9%20n%C2%B0%20177-06.pdf
http://SIUJ.org

