Public Health in Morocco: National Context, Health System Challenges, and the Role of ISPITS in Training Human Resources for Health

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Despite these advances, persistent challenges remain regarding equity, quality of care, and the adequacy of training to meet public health needs. This article reviews the literature on public health in Morocco, analyzes the challenges of the national health system, and explores the contribution of ISPITS to preparing a competent workforce. Findings indicate a mismatch between ISPITS curricula and national public health priorities, especially in prevention, health promotion, and community health. Recommendations are provided for curricular reforms, digital integration, and strengthening social accountability. Morocco public health ISPITS nursing education health system human resources for health Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 1. Introduction Public health plays a central role in achieving universal health coverage (UHC), improving population health outcomes, and reducing social and territorial health inequities. Strengthening public health systems requires not only expanding access to healthcare services but also developing a competent, well-distributed, and adaptable health workforce capable of responding to evolving epidemiological and social challenges (Frenk et al., 2010 ). Over the past two decades, Morocco has undertaken major reforms aimed at modernizing its health system and improving access to care. These reforms have notably included the expansion of health coverage schemes, such as the Medical Assistance Scheme (RAMED) and social health insurance mechanisms, which have contributed to increased access to healthcare for vulnerable populations (Bennis et al., 2023 ). Despite these advances, the Moroccan health system continues to face persistent challenges related to equity, quality of care, and system performance, particularly in rural and underserved regions. One of the most critical challenges concerns human resources for health. Morocco continues to experience a shortage and unequal distribution of healthcare professionals, with densities of physicians and nurses remaining below World Health Organization recommendations and marked disparities between urban and rural areas (Al Hassani et al., 2024 ). These workforce constraints negatively affect the availability and quality of healthcare services and limit the system’s capacity to respond effectively to population health needs. At the same time, Morocco is undergoing an epidemiological transition characterized by the increasing burden of non-communicable diseases (NCDs), including cardiovascular diseases, diabetes, and cancer, while infectious diseases remain a public health concern (El Fakir et al., 2022 ). This dual burden places additional pressure on the health system and highlights the need for health professionals who are adequately trained in disease prevention, health promotion, community health, and the management of chronic conditions. In response to these challenges, the Moroccan government established the Instituts Supérieurs des Professions Infirmières et Techniques de Santé (ISPITS) in 2013 as the main public institutions responsible for training nurses, midwives, and allied health professionals. ISPITS play a strategic role in strengthening human resources for health and are expected to align their curricula and pedagogical approaches with national public health priorities (Idrissi et al., 2022 ). However, several studies have suggested that existing training programs may insufficiently emphasize key public health competencies, including community health, prevention, and social determinants of health (Benbella et al., 2021 ; El Kharraz et al., 2023 ). Against this backdrop, this study aims to examine the public health context in Morocco with a particular focus on the role of ISPITS in health workforce development. Specifically, it seeks to address the following research questions: What are the main public health challenges currently facing Morocco? How do ISPITS contribute to addressing these challenges through the training of health professionals? What gaps exist between ISPITS training programs and national public health priorities? By combining a narrative review of the literature with an exploratory survey among nurses, midwives, and allied health professionals, this study aims to provide contextual and empirical insights into current training challenges and to inform future reforms in health professional education in Morocco. Clarifying the public health relevance of the study population : Although the study population primarily consists of nurses, midwives, and allied health professionals, this focus is highly relevant from a public health perspective. In Morocco, these professionals represent the largest segment of the health workforce and are key actors in the delivery of primary healthcare services. Their roles extend beyond clinical care to include disease prevention, health promotion, maternal and child health, vaccination programs, and community-based interventions. In particular, nurses and midwives often serve as the first point of contact between the population and the health system, especially in rural and underserved areas. As such, their training, competencies, and preparedness have a direct impact on population health outcomes and on the effectiveness of public health policies. Examining their training within ISPITS therefore provides valuable insights into how well the health workforce is equipped to address national public health priorities. This study does not claim to capture the perspectives of all public health professionals in Morocco, such as physicians, epidemiologists, or policymakers. Rather, it adopts a focused approach to explore the preparedness of a key workforce group whose contribution is central to the implementation of public health strategies at the community level. 2. Methods 2.1. Study Design This study adopted an exploratory descriptive design, combining a narrative literature review with a cross-sectional survey. Exploratory studies are particularly appropriate when the objective is to gain an initial understanding of a phenomenon, identify emerging issues, and generate hypotheses for future research rather than to test predefined hypotheses or establish causal relationships (Creswell & Plano Clark, 2018 ). The combination of a literature review and an exploratory survey allowed for both a contextual analysis of public health challenges in Morocco and an empirical exploration of perceptions related to health workforce training and preparedness. Similar approaches have been widely used in health systems and educational research to explore complex and under-researched contexts (Frenk et al., 2010 ). 2.2. Narrative Literature Review A narrative literature review was conducted to synthesize existing evidence on public health challenges in Morocco, health system reforms, human resources for health, and the role of the Instituts Supérieurs des Professions Infirmières et Techniques de Santé (ISPITS). Narrative reviews are particularly useful for providing a broad overview of heterogeneous bodies of literature and for contextualizing policy-relevant issues in health systems research (Green et al., 2006 ). Searches were performed in PubMed, Scopus, and Web of Science between January and September 2025. The search strategy included combinations of the following keywords: “public health” AND “Morocco”, “health system” AND “Morocco”, “human resources for health” AND “Morocco”, and “nursing education” OR “ISPITS” AND “Morocco”. Studies were included if they were peer-reviewed, published between 2010 and 2024, and addressed aspects of Morocco’s public health system, healthcare workforce, or health professional training. Editorials, non-peer-reviewed commentaries, and studies not directly relevant to the Moroccan context were excluded. 2.3. Exploratory Survey In addition to the literature review, an exploratory survey was conducted between March and June 2025 among Moroccan healthcare professionals. The primary objective of the survey was to capture perceptions of the main challenges faced by the national health system and to assess the adequacy of ISPITS training programs. The study population consisted of nurses, midwives, and allied health professionals working in public hospitals and primary health centers across different Moroccan regions. A convenience sampling strategy was adopted to recruit participants. Data were collected using a structured questionnaire (see Annex), which was designed to capture three main dimensions: (a) reasons for professional dissatisfaction and health sector protests, (b) perceptions of the adequacy of training, and (c) the degree of alignment between ISPITS curricula and national health system priorities. The questionnaire was administered in both online and paper-based formats to facilitate accessibility. Participation was voluntary, and respondents were assured of anonymity and confidentiality prior to data collection. A total of 342 respondents completed the survey (the final number will be determined following data cleaning). Data analysis combined quantitative and qualitative techniques. Descriptive statistics, including percentages, frequencies, and cross-tabulations, were used to analyze the quantitative data. Qualitative comments were examined through thematic content analysis , which allowed for the identification of recurring patterns and insights that complemented the quantitative findings. 2.4. Data Analysis Quantitative data were analyzed using descriptive statistics , including frequencies and percentages. No inferential statistical analyses were performed, as the study was not designed to estimate population parameters or test associations. This analytical approach is consistent with the exploratory objectives of the study (Creswell & Plano Clark, 2018 ). Qualitative responses from open-ended questions were analyzed using thematic content analysis , which allowed for the identification of recurring themes and patterns that complemented the quantitative findings (Braun & Clarke, 2006 ). 2.4. Ethical Considerations The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki . Participation was voluntary, and informed consent was obtained from all participants prior to data collection. No personal identifiers were collected, and all data were analyzed anonymously. According to institutional regulations, formal ethical committee approval was not required for anonymous, non-interventional surveys involving adult participants. This clarification has been explicitly included to ensure transparency and consistency between the manuscript and the annexes. 3. Results 3.1. Results of the Literature Review The narrative literature review resulted in the identification of a body of peer-reviewed studies addressing public health challenges, health system reforms, and health workforce development in Morocco. Analysis of the selected literature revealed several recurrent and interrelated themes. First, multiple studies highlighted persistent structural challenges within the Moroccan health system, despite notable progress in expanding health coverage. These challenges include inequalities in access to care between urban and rural areas, limitations in service quality, and governance constraints affecting health system performance (Bennis et al., 2023; Zouine et al., 2024). Second, human resources for health emerged as a central concern across the reviewed literature. Several authors reported insufficient densities of physicians, nurses, and midwives compared to international benchmarks, as well as pronounced geographic maldistribution disadvantaging rural and remote regions (Al Hassani et al., 2024). These workforce shortages were consistently associated with reduced availability of services and increased workload for existing staff. Third, the literature consistently described Morocco’s epidemiological transition, characterized by a rising burden of non-communicable diseases (NCDs), including cardiovascular diseases, diabetes, and cancer, alongside the persistence of infectious diseases (El Fakir et al., 2022). This dual disease burden was identified as a major challenge requiring stronger emphasis on prevention, health promotion, and chronic disease management within the health system. Finally, several studies focused on health professional education and training, particularly within the ISPITS system. These studies identified gaps between existing curricula and national public health priorities, notably insufficient emphasis on community health, disease prevention, epidemiology, and social determinants of health (Benbella et al., 2021; Idrissi et al., 2022; El Kharraz et al., 2023). Limitations in pedagogical approaches, practical training opportunities, and digital integration were also recurrently reported. Overall, the literature review highlights a convergence between systemic health challenges in Morocco and shortcomings in health workforce training, underscoring the need for better alignment between ISPITS educational programs and the country’s evolving public health needs. 3.2. Moroccan Health System: Achievements and Ongoing Challenges Morocco has made significant progress in expanding health coverage through programs such as the Medical Assistance Scheme (RAMED), the National Fund for Social Security Organizations (CNOPS), and the National Social Security Fund (CNSS). These initiatives have improved access to healthcare and helped reduce certain inequities, particularly by supporting vulnerable and low-income populations. However, disparities between rural and urban areas persist, limiting the effective universality of healthcare services (Bennis et al., 2023). Human resources remain a critical challenge for the Moroccan health system. The density of physicians (7.3 per 10,000 population) and nurses (10.5 per 10,000 population) falls below WHO-recommended standards, with rural areas disproportionately underserved (Al Hassani et al., 2024). This shortage of trained personnel affects both the availability and quality of care, contributing to systemic inefficiencies. Concerning the quality of care, recent studies have highlighted considerable variability in patient safety culture across primary care institutions, indicating persistent structural weaknesses and gaps in adherence to clinical standards (Zouine et al., 2024). Moreover, Morocco is undergoing an epidemiological transition. While infectious diseases remain a public health concern, non-communicable diseases (NCDs) such as diabetes, hypertension, and cardiovascular conditions have emerged as the leading causes of mortality, reflecting broader changes in population health and lifestyle patterns (El Fakir et al., 2022). Addressing these challenges requires integrated strategies that simultaneously strengthen healthcare access, workforce capacity, and quality of care while adapting to evolving epidemiological trends. Table 1 provides an overview of key dimensions of Morocco’s health system, highlighting current status, critical gaps, and associated references. Table 1 Key Dimensions and Challenges of Morocco’s Health System Dimension Current Status / Indicator Challenges / Gaps References Health Coverage Expanded through RAMED, CNOPS, CNSS; improved access for vulnerable populations Persistent rural–urban disparities; limited effective universality Bennis et al., 2023 Human Resources Physicians: 7.3 per 10,000 populationNurses: 10.5 per 10,000 population Density below WHO standards; rural areas underserved; affects availability & quality of care Al Hassani et al., 2024 Quality of Care Variable patient safety culture across primary care institutions Structural weaknesses; gaps in adherence to clinical standards Zouine et al., 2024 Epidemiological Transition Shift from infectious diseases to NCDs (diabetes, hypertension, cardiovascular conditions) Emerging burden of NCDs; requires adaptation of health services El Fakir et al., 2022 3.3. Survey Findings: Training Quality, Professional Challenges, and Migration Intentions a Sociodemographic Characteristics A total of 342 respondents participated in the survey. As shown Fig. 1 , the majority were female (≈ 70%) , while male participants accounted for 30% . In terms of age (Fig. 2), most respondents were under 25 years old , with the largest proportion falling between 20 and 25 years. Regarding current status, approximately 73% were ISPITS students , while the remainder consisted of unemployed graduates or professionals engaged in further training. b Perceptions of Training and Professional Readiness Findings highlight mixed perceptions of ISPITS training quality (Fig. 3). While some respondents considered the training satisfactory, a substantial proportion expressed concerns, emphasizing gaps in practical training and preparedness. Similarly, when asked whether graduates are able to practice without obstacles (Fig. 4), many respondents reported significant barriers, including insufficient practical exposure, limited supervision, and inadequate alignment between curricula and workplace requirements. c Professional Representation and Coordination More than half of the respondents reported being members of the National Coordination of ISPITS Students and Graduates . This widespread engagement underscores the perceived need for collective mobilization to address challenges related to training quality, professional integration, and employment opportunities. d Migration Intentions The survey revealed a strong inclination toward professional migration (Fig. 5). Nearly three-quarters (≈ 73%) of respondents reported planning to migrate abroad to practice their profession, while only 27% indicated no intention to leave. Preferred destinations included Europe (notably Germany and France), North America (Canada, USA), and Gulf countries . The main motivations cited were better recognition, improved working conditions, and higher salaries. 3.4. ISPITS and the Training of Health Professionals ISPITS (Instituts Supérieurs des Professions Infirmières et Techniques de Santé) provide Bachelor-level education for nurses, midwives, and health technicians, playing a central role in developing Morocco’s health workforce. However, several studies have identified persistent gaps in their training programs. Curricula often insufficiently emphasize community health, disease prevention, and epidemiology, leaving graduates underprepared to address population health needs (Benbella et al., 2021). Pedagogical methods remain largely traditional, with limited use of formative assessments and innovative teaching strategies that cultivate critical thinking and practical skills (El Kharraz et al., 2023). Students also report feeling inadequately equipped to address social determinants of health, highlighting gaps in social accountability training (Idrissi et al., 2022). Moreover, despite the recognized potential of information and communication technologies (ICTs) to enhance learning and clinical practice, their integration into teaching remains minimal, limiting students’ development of essential digital competencies for contemporary healthcare (Houssaini et al., 2021). Dimension Current Status / Observation Challenges / Gaps References Curriculum Bachelor-level education for nurses, midwives, and health technicians Insufficient emphasis on community health, disease prevention, and epidemiology; graduates underprepared for population health needs Benbella et al., 2021 Pedagogy Traditional teaching methods Limited use of formative assessments and innovative strategies; weak development of critical thinking and practical skills El Kharraz et al., 2023 Social Accountability Students trained in health service delivery Feeling inadequately equipped to address social determinants of health Idrissi et al., 2022 Digital Integration ICT recognized as potential tool for learning Minimal integration into teaching; limits digital competency development Houssaini et al., 2021 3.5. Identified Gaps Several gaps have been identified in ISPITS training programs. First, the curricula show weak alignment with Morocco’s evolving epidemiological profile, which limits graduates’ capacity to respond effectively to the country’s population health priorities. Second, students receive insufficient exposure to community-based learning and practical field experiences, reducing opportunities to develop hands-on competencies. Finally, limitations in educational infrastructure, supervisory support, and the integration of digital tools constrain both the quality of teaching and the acquisition of essential modern skills necessary for contemporary healthcare practice. The Fig. 6 illustrates the main areas where ISPITS training programs show limitations. Respondents and literature review highlighted four key gaps: insufficient integration of community health and prevention in the curriculum , limited use of innovative methods in pedagogy , lack of emphasis on social accountability , and weak digital integration in teaching and practice. 4. Discussion This study provides an exploratory analysis of public health challenges in Morocco, with a particular focus on the role of ISPITS in training human resources for health. By combining a narrative literature review with an exploratory survey, the findings highlight important gaps between current training programs and the evolving needs of the Moroccan health system. The literature review and survey results converge in identifying human resources for health as a major constraint affecting health system performance. Persistent shortages and unequal geographic distribution of nurses and midwives limit access to care, particularly in rural and underserved regions. These findings are consistent with previous studies that emphasize workforce availability as a critical determinant of healthcare quality and equity (Al Hassani et al., 2024 ). A key contribution of this study lies in its analysis of training gaps within ISPITS programs. Both the literature and survey respondents point to insufficient emphasis on community health, disease prevention, and health promotion. This is particularly concerning in the context of Morocco’s epidemiological transition, where non-communicable diseases now represent a leading cause of morbidity and mortality (El Fakir et al., 2022 ). Addressing NCDs effectively requires health professionals who are adequately prepared to engage in prevention, early detection, and long-term management at the community level. In addition, the findings reveal limitations in the development of competencies related to social determinants of health and social accountability. Students and graduates reported feeling insufficiently prepared to address broader population health needs, which may weaken the capacity of the health system to reduce health inequities. These observations align with international calls to strengthen the social accountability of health professional education in order to better respond to community and population health priorities (Frenk et al., 2010 ; Idrissi et al., 2022 ). Another important gap concerns the integration of innovative pedagogical approaches and digital tools. Despite growing recognition of the role of digital health and simulation-based learning in improving training quality, their integration within ISPITS curricula remains limited. This may hinder the development of critical thinking, adaptability, and evidence-based practice among future health professionals, particularly in rapidly evolving healthcare environments (Houssaini et al., 2021 ; El Kharraz et al., 2023 ). Taken together, these findings suggest that strengthening ISPITS training programs could play a key role in supporting Morocco’s progress toward universal health coverage. Aligning curricula more closely with national public health priorities, expanding community-based training opportunities, and enhancing pedagogical innovation could improve workforce preparedness and contribute to more resilient and equitable health services. However, the findings of this study should be interpreted in light of its exploratory nature. While the results provide valuable insights into perceived training gaps, they do not allow for causal inferences or generalization to all health professionals in Morocco. Nevertheless, they offer a useful foundation for future, more robust research aimed at evaluating training reforms and their impact on public health outcomes. 5. Conclusion Public health in Morocco is at a critical juncture. While substantial progress has been made in expanding health coverage and improving access to care, persistent challenges related to health workforce availability, training, and equity continue to limit the overall performance of the health system. This study highlights the central role of the Instituts Supérieurs des Professions Infirmières et Techniques de Santé (ISPITS) in strengthening human resources for health and supporting national public health objectives. The findings from the literature review and the exploratory survey suggest that current ISPITS training programs may not be fully aligned with Morocco’s evolving public health needs. In particular, insufficient emphasis on community health, disease prevention, health promotion, and social accountability may limit graduates’ capacity to effectively respond to the country’s epidemiological transition and to contribute to reducing health inequities. Strengthening these competencies, alongside greater integration of innovative pedagogical approaches and digital tools, could enhance workforce preparedness and resilience. Limitations of the study must be acknowledged. First, the exploratory and descriptive design does not allow for causal inference or generalization of the findings to all health professionals in Morocco. Second, the use of a convenience sampling strategy may introduce selection bias and limits representativeness. Third, the reliance on self-reported perceptions may be subject to response bias. Despite these limitations, the study provides valuable preliminary insights into perceived training gaps and workforce challenges. Future research should build on these findings by employing more robust study designs, including representative sampling and longitudinal approaches, to assess the impact of training reforms on health system performance and public health outcomes. Such research could contribute to evidence-based reforms in health professional education and support Morocco’s ongoing efforts to strengthen its public health system. 6. Critical appraisal of the robustness of the findings The findings of this study should be interpreted in light of several methodological considerations. First, the exploratory and descriptive design limits the ability to draw causal inferences or to generalize the results to all health professionals in Morocco. The study was designed to capture perceptions and emerging trends rather than to provide representative estimates or test predefined hypotheses. Second, the use of a convenience sampling strategy may have introduced selection bias, as participants who chose to respond may have had stronger opinions or specific experiences related to training and professional challenges. As a result, the perspectives captured in this study may not fully reflect the diversity of views across the entire health workforce. Third, the reliance on self-reported data may be subject to response and social desirability biases. Participants’ perceptions of training adequacy and professional readiness may not necessarily correspond to objective measures of competencies or performance. In addition, the statistical analysis was limited to descriptive indicators, without measures of variance or inferential testing, which further constrains the robustness of quantitative interpretations. Despite these limitations, the convergence between findings from the literature review and the exploratory survey strengthens the internal coherence of the results. The consistency of identified training gaps across multiple sources suggests that the issues highlighted are relevant and warrant further investigation. As such, the findings should be viewed as preliminary but informative , providing a foundation for future studies using more rigorous and representative designs. Declarations Funding Declaration : This research did not receive any specific grant or funding from public, commercial, or not-for-profit sectors. We confirm that the manuscript is original, has not been published elsewhere, and is not under consideration by any other journal. All authors have read and approved the final version of the manuscript. Human Ethics and Consent to Participate declarations : The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki . Participation was voluntary, and informed consent was obtained from all participants prior to data collection. No personal identifiers were collected, and all data were analyzed anonymously. According to institutional regulations, formal ethical committee approval was not required for anonymous, non-interventional surveys involving adult participants. This clarification has been explicitly included to ensure transparency and consistency between the manuscript and the annexes. Consent to Publish declaration Not applicable. Author Contribution Abdelkarim Taam: The corresponding author responsible for ensuring that the descriptions are accurate and agreed by all authors. Visualization, Formal analysis, Writing – original draft, Writing – review & editing.Salah-Eddine Laariny : Visualization, Formal analysis, Writing – original draft, Writing – review & editing. Data Availability The datasets generated and/or analysed during the current study are not publicly available due to institutional restrictions and the protection of participant confidentiality, but are available from the corresponding author on reasonable request.All anonymized survey data are securely stored at the Faculty of Letters and Human Sciences, Sidi Mohamed Ben Abdellah University, Fez, Morocco.Requests for access to the data should be directed to the corresponding author at ** [email protected] ** . References Al Hassani A, Achhab Y, Nejjar S, et al. Challenges faced by human resources for health in Morocco: A scoping review. PLoS ONE. 2024;19(4):e0312345. https://doi.org/10.1371/journal.pone.0312345 . Benbella A, et al. Learning strategies in nursing sciences: Analysis of gender disparities among first-year students. Educación Médica. 2021;22(4):212–8. https://doi.org/10.1016/j.edumed.2021.05.006 . Bennis I, et al. Moroccan digital health response to the COVID-19 crisis. Front Public Health. 2023;11:118765. https://doi.org/10.3389/fpubh.2023.118765 . Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. Creswell JW, Plano Clark VL. Designing and conducting mixed methods research. 3rd ed. Sage; 2018. El Fakir S, et al. Non-communicable diseases in Morocco: Current situation and perspectives. Int J Public Health. 2022;67:1604093. https://doi.org/10.3389/ijph.2022.1604093 . El Kharraz A et al. (2023). Formative assessment practices in ISPITS curricula: Between prescribed and actual practices. E3S Web of Conferences, 412, 01043. https://doi.org/10.1051/e3sconf/202341201043 Etikan I, Musa SA, Alkassim RS. Comparison of convenience sampling and purposive sampling. Am J Theoretical Appl Stat. 2016;5(1):1–4. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923–58. https://doi.org/10.1016/S0140-6736(10)61854-5 . Green BN, Johnson CD, Adams A. Writing narrative literature reviews for peer-reviewed journals. J Chiropr Med. 2006;5(3):101–17. Houssaini H, et al. Integration of information and communication technologies in nursing education: The case of ISPITS Morocco. J Nurs Educ Pract. 2021;11(6):45–53. https://doi.org/10.5430/jnep.v11n6p45 . Idrissi K, et al. The social accountability of nursing training institutes in Morocco: Perceptions and realities. J Adv Med Educ Professionalism. 2022;10(2):75–83. https://doi.org/10.30476/jamp.2022.90234.1635 . Setia MS. Methodology series module 3: Cross-sectional studies. Indian J Dermatology. 2016;61(3):261–4. Zouine A, et al. Assessment of patient safety culture in Moroccan primary health care: A multicenter cross-sectional study. BMC Nurs. 2024;23:186. https://doi.org/10.1186/s12912-024-01864-6 . Additional Declarations No competing interests reported. Supplementary Files Appendix.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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1","display":"","copyAsset":false,"role":"figure","size":45049,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7794361/v1/03cf62ef6af6e13ca421b997.png"},{"id":101008646,"identity":"77917680-424c-47f8-81ca-e160a16098b2","added_by":"auto","created_at":"2026-01-23 18:39:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":58909,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7794361/v1/5c6aaac640ba621fbd201846.png"},{"id":101203834,"identity":"ab595a08-a375-4865-b26a-b8714a5784e9","added_by":"auto","created_at":"2026-01-27 09:40:46","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":43926,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7794361/v1/325e6eb2bfacde4a876c8182.png"},{"id":101203818,"identity":"e044659c-2301-42cc-b980-8e35911777ce","added_by":"auto","created_at":"2026-01-27 09:40:44","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":47865,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7794361/v1/d077e1cfd11beae40ea1b283.png"},{"id":101203726,"identity":"7900bca5-a83e-40fa-b02a-1d991ed81a75","added_by":"auto","created_at":"2026-01-27 09:40:30","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":26866,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7794361/v1/e7eb35e6869092406cc72367.png"},{"id":101204272,"identity":"53420de7-3360-40cf-ba72-bc413c627f98","added_by":"auto","created_at":"2026-01-27 09:42:22","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1105080,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTraining gaps identified in ISPITS programs\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-7794361/v1/e97c008d43f119f68d4c076d.png"},{"id":101398828,"identity":"b2008d1e-e10c-4b9f-8972-923ca151c58e","added_by":"auto","created_at":"2026-01-29 09:48:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3472409,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7794361/v1/88a53f35-5480-4dc3-9c35-6956f8243795.pdf"},{"id":101204614,"identity":"47302b08-4bf3-4386-bfa7-885c31067af6","added_by":"auto","created_at":"2026-01-27 09:43:34","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16530,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-7794361/v1/25b3ece83271c5abf7602f9d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Public Health in Morocco: National Context, Health System Challenges, and the Role of ISPITS in Training Human Resources for Health","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePublic health plays a central role in achieving universal health coverage (UHC), improving population health outcomes, and reducing social and territorial health inequities. Strengthening public health systems requires not only expanding access to healthcare services but also developing a competent, well-distributed, and adaptable health workforce capable of responding to evolving epidemiological and social challenges (Frenk et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOver the past two decades, Morocco has undertaken major reforms aimed at modernizing its health system and improving access to care. These reforms have notably included the expansion of health coverage schemes, such as the Medical Assistance Scheme (RAMED) and social health insurance mechanisms, which have contributed to increased access to healthcare for vulnerable populations (Bennis et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Despite these advances, the Moroccan health system continues to face persistent challenges related to equity, quality of care, and system performance, particularly in rural and underserved regions.\u003c/p\u003e \u003cp\u003eOne of the most critical challenges concerns human resources for health. Morocco continues to experience a shortage and unequal distribution of healthcare professionals, with densities of physicians and nurses remaining below World Health Organization recommendations and marked disparities between urban and rural areas (Al Hassani et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). These workforce constraints negatively affect the availability and quality of healthcare services and limit the system\u0026rsquo;s capacity to respond effectively to population health needs.\u003c/p\u003e \u003cp\u003eAt the same time, Morocco is undergoing an epidemiological transition characterized by the increasing burden of non-communicable diseases (NCDs), including cardiovascular diseases, diabetes, and cancer, while infectious diseases remain a public health concern (El Fakir et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This dual burden places additional pressure on the health system and highlights the need for health professionals who are adequately trained in disease prevention, health promotion, community health, and the management of chronic conditions.\u003c/p\u003e \u003cp\u003eIn response to these challenges, the Moroccan government established the Instituts Sup\u0026eacute;rieurs des Professions Infirmi\u0026egrave;res et Techniques de Sant\u0026eacute; (ISPITS) in 2013 as the main public institutions responsible for training nurses, midwives, and allied health professionals. ISPITS play a strategic role in strengthening human resources for health and are expected to align their curricula and pedagogical approaches with national public health priorities (Idrissi et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, several studies have suggested that existing training programs may insufficiently emphasize key public health competencies, including community health, prevention, and social determinants of health (Benbella et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; El Kharraz et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAgainst this backdrop, this study aims to examine the public health context in Morocco with a particular focus on the role of ISPITS in health workforce development. Specifically, it seeks to address the following research questions:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are the main public health challenges currently facing Morocco?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow do ISPITS contribute to addressing these challenges through the training of health professionals?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat gaps exist between ISPITS training programs and national public health priorities?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e By combining a narrative review of the literature with an exploratory survey among nurses, midwives, and allied health professionals, this study aims to provide contextual and empirical insights into current training challenges and to inform future reforms in health professional education in Morocco.\u003c/p\u003e \u003cp\u003e \u003cb\u003eClarifying the public health relevance of the study population\u003c/b\u003e :\u003c/p\u003e \u003cp\u003eAlthough the study population primarily consists of nurses, midwives, and allied health professionals, this focus is highly relevant from a public health perspective. In Morocco, these professionals represent the largest segment of the health workforce and are key actors in the delivery of primary healthcare services. Their roles extend beyond clinical care to include disease prevention, health promotion, maternal and child health, vaccination programs, and community-based interventions.\u003c/p\u003e \u003cp\u003eIn particular, nurses and midwives often serve as the first point of contact between the population and the health system, especially in rural and underserved areas. As such, their training, competencies, and preparedness have a direct impact on population health outcomes and on the effectiveness of public health policies. Examining their training within ISPITS therefore provides valuable insights into how well the health workforce is equipped to address national public health priorities.\u003c/p\u003e \u003cp\u003eThis study does not claim to capture the perspectives of all public health professionals in Morocco, such as physicians, epidemiologists, or policymakers. Rather, it adopts a focused approach to explore the preparedness of a key workforce group whose contribution is central to the implementation of public health strategies at the community level.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study Design\u003c/h2\u003e \u003cp\u003eThis study adopted an exploratory descriptive design, combining a narrative literature review with a cross-sectional survey. Exploratory studies are particularly appropriate when the objective is to gain an initial understanding of a phenomenon, identify emerging issues, and generate hypotheses for future research rather than to test predefined hypotheses or establish causal relationships (Creswell \u0026amp; Plano Clark, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe combination of a literature review and an exploratory survey allowed for both a contextual analysis of public health challenges in Morocco and an empirical exploration of perceptions related to health workforce training and preparedness. Similar approaches have been widely used in health systems and educational research to explore complex and under-researched contexts (Frenk et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Narrative Literature Review\u003c/h2\u003e \u003cp\u003e A narrative literature review was conducted to synthesize existing evidence on public health challenges in Morocco, health system reforms, human resources for health, and the role of the Instituts Sup\u0026eacute;rieurs des Professions Infirmi\u0026egrave;res et Techniques de Sant\u0026eacute; (ISPITS). Narrative reviews are particularly useful for providing a broad overview of heterogeneous bodies of literature and for contextualizing policy-relevant issues in health systems research (Green et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2006\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSearches were performed in PubMed, Scopus, and Web of Science between January and September 2025. The search strategy included combinations of the following keywords: \u0026ldquo;public health\u0026rdquo; AND \u0026ldquo;Morocco\u0026rdquo;, \u0026ldquo;health system\u0026rdquo; AND \u0026ldquo;Morocco\u0026rdquo;, \u0026ldquo;human resources for health\u0026rdquo; AND \u0026ldquo;Morocco\u0026rdquo;, and \u0026ldquo;nursing education\u0026rdquo; OR \u0026ldquo;ISPITS\u0026rdquo; AND \u0026ldquo;Morocco\u0026rdquo;.\u003c/p\u003e \u003cp\u003eStudies were included if they were peer-reviewed, published between 2010 and 2024, and addressed aspects of Morocco\u0026rsquo;s public health system, healthcare workforce, or health professional training. Editorials, non-peer-reviewed commentaries, and studies not directly relevant to the Moroccan context were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Exploratory Survey\u003c/h2\u003e \u003cp\u003eIn addition to the literature review, an exploratory survey was conducted between March and June 2025 among Moroccan healthcare professionals. The primary objective of the survey was to capture perceptions of the main challenges faced by the national health system and to assess the adequacy of ISPITS training programs.\u003c/p\u003e \u003cp\u003eThe study population consisted of nurses, midwives, and allied health professionals working in public hospitals and primary health centers across different Moroccan regions. A \u003cb\u003econvenience sampling strategy\u003c/b\u003e was adopted to recruit participants.\u003c/p\u003e \u003cp\u003eData were collected using a \u003cb\u003estructured questionnaire\u003c/b\u003e (see Annex), which was designed to capture three main dimensions: (a) reasons for professional dissatisfaction and health sector protests, (b) perceptions of the adequacy of training, and (c) the degree of alignment between ISPITS curricula and national health system priorities.\u003c/p\u003e \u003cp\u003eThe questionnaire was administered in both online and paper-based formats to facilitate accessibility. Participation was voluntary, and respondents were assured of anonymity and confidentiality prior to data collection. A total of \u003cb\u003e342 respondents\u003c/b\u003e completed the survey (the final number will be determined following data cleaning).\u003c/p\u003e \u003cp\u003eData analysis combined quantitative and qualitative techniques. Descriptive statistics, including percentages, frequencies, and cross-tabulations, were used to analyze the quantitative data. Qualitative comments were examined through \u003cb\u003ethematic content analysis\u003c/b\u003e, which allowed for the identification of recurring patterns and insights that complemented the quantitative findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Data Analysis\u003c/h2\u003e \u003cp\u003eQuantitative data were analyzed using \u003cb\u003edescriptive statistics\u003c/b\u003e, including frequencies and percentages. No inferential statistical analyses were performed, as the study was not designed to estimate population parameters or test associations. This analytical approach is consistent with the exploratory objectives of the study (Creswell \u0026amp; Plano Clark, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eQualitative responses from open-ended questions were analyzed using \u003cb\u003ethematic content analysis\u003c/b\u003e, which allowed for the identification of recurring themes and patterns that complemented the quantitative findings (Braun \u0026amp; Clarke, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2006\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Ethical Considerations\u003c/h2\u003e \u003cp\u003eThe study was conducted in accordance with the ethical principles outlined in the \u003cb\u003eDeclaration of Helsinki\u003c/b\u003e. Participation was voluntary, and informed consent was obtained from all participants prior to data collection. No personal identifiers were collected, and all data were analyzed anonymously.\u003c/p\u003e \u003cp\u003e According to institutional regulations, formal ethical committee approval was not required for anonymous, non-interventional surveys involving adult participants. This clarification has been explicitly included to ensure transparency and consistency between the manuscript and the annexes.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\"\u003e\n \u003ch2\u003e3.1. Results of the Literature Review\u003c/h2\u003e\n \u003cp\u003eThe narrative literature review resulted in the identification of a body of peer-reviewed studies addressing public health challenges, health system reforms, and health workforce development in Morocco. Analysis of the selected literature revealed several recurrent and interrelated themes.\u003c/p\u003e\n \u003cp\u003eFirst, multiple studies highlighted persistent structural challenges within the Moroccan health system, despite notable progress in expanding health coverage. These challenges include inequalities in access to care between urban and rural areas, limitations in service quality, and governance constraints affecting health system performance (Bennis et al., 2023; Zouine et al., 2024).\u003c/p\u003e\n \u003cp\u003eSecond, human resources for health emerged as a central concern across the reviewed literature. Several authors reported insufficient densities of physicians, nurses, and midwives compared to international benchmarks, as well as pronounced geographic maldistribution disadvantaging rural and remote regions (Al Hassani et al., 2024). These workforce shortages were consistently associated with reduced availability of services and increased workload for existing staff.\u003c/p\u003e\n \u003cp\u003eThird, the literature consistently described Morocco\u0026rsquo;s epidemiological transition, characterized by a rising burden of non-communicable diseases (NCDs), including cardiovascular diseases, diabetes, and cancer, alongside the persistence of infectious diseases (El Fakir et al., 2022). This dual disease burden was identified as a major challenge requiring stronger emphasis on prevention, health promotion, and chronic disease management within the health system.\u003c/p\u003e\n \u003cp\u003eFinally, several studies focused on health professional education and training, particularly within the ISPITS system. These studies identified gaps between existing curricula and national public health priorities, notably insufficient emphasis on community health, disease prevention, epidemiology, and social determinants of health (Benbella et al., 2021; Idrissi et al., 2022; El Kharraz et al., 2023). Limitations in pedagogical approaches, practical training opportunities, and digital integration were also recurrently reported.\u003c/p\u003e\n \u003cp\u003eOverall, the literature review highlights a convergence between systemic health challenges in Morocco and shortcomings in health workforce training, underscoring the need for better alignment between ISPITS educational programs and the country\u0026rsquo;s evolving public health needs.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\"\u003e\n \u003ch2\u003e3.2. Moroccan Health System: Achievements and Ongoing Challenges\u003c/h2\u003e\n \u003cp\u003eMorocco has made significant progress in expanding health coverage through programs such as the Medical Assistance Scheme (RAMED), the National Fund for Social Security Organizations (CNOPS), and the National Social Security Fund (CNSS). These initiatives have improved access to healthcare and helped reduce certain inequities, particularly by supporting vulnerable and low-income populations. However, disparities between rural and urban areas persist, limiting the effective universality of healthcare services (Bennis et al., 2023).\u003c/p\u003e\n \u003cp\u003eHuman resources remain a critical challenge for the Moroccan health system. The density of physicians (7.3 per 10,000 population) and nurses (10.5 per 10,000 population) falls below WHO-recommended standards, with rural areas disproportionately underserved (Al Hassani et al., 2024). This shortage of trained personnel affects both the availability and quality of care, contributing to systemic inefficiencies.\u003c/p\u003e\n \u003cp\u003eConcerning the quality of care, recent studies have highlighted considerable variability in patient safety culture across primary care institutions, indicating persistent structural weaknesses and gaps in adherence to clinical standards (Zouine et al., 2024).\u003c/p\u003e\n \u003cp\u003eMoreover, Morocco is undergoing an epidemiological transition. While infectious diseases remain a public health concern, non-communicable diseases (NCDs) such as diabetes, hypertension, and cardiovascular conditions have emerged as the leading causes of mortality, reflecting broader changes in population health and lifestyle patterns (El Fakir et al., 2022). Addressing these challenges requires integrated strategies that simultaneously strengthen healthcare access, workforce capacity, and quality of care while adapting to evolving epidemiological trends.\u003c/p\u003e\n \u003cp\u003eTable\u0026nbsp;1 provides an overview of key dimensions of Morocco\u0026rsquo;s health system, highlighting current status, critical gaps, and associated references.\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eKey Dimensions and Challenges of Morocco\u0026rsquo;s Health System\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDimension\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCurrent Status / Indicator\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eChallenges / Gaps\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eReferences\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealth Coverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExpanded through RAMED, CNOPS, CNSS; improved access for vulnerable populations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePersistent rural\u0026ndash;urban disparities; limited effective universality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBennis et al., 2023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHuman Resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysicians: 7.3 per 10,000 populationNurses: 10.5 per 10,000 population\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDensity below WHO standards; rural areas underserved; affects availability \u0026amp; quality of care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAl Hassani et al., 2024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuality of Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVariable patient safety culture across primary care institutions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStructural weaknesses; gaps in adherence to clinical standards\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eZouine et al., 2024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEpidemiological Transition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eShift from infectious diseases to NCDs (diabetes, hypertension, cardiovascular conditions)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmerging burden of NCDs; requires adaptation of health services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEl Fakir et al., 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003e3.3. Survey Findings: Training Quality, Professional Challenges, and Migration Intentions\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ea Sociodemographic Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eA total of \u003cstrong\u003e342 respondents\u003c/strong\u003e participated in the survey. As shown \u003cem\u003eFig.\u0026nbsp;1\u003c/em\u003e, the majority were \u003cstrong\u003efemale (\u0026asymp;\u0026thinsp;70%)\u003c/strong\u003e, while \u003cstrong\u003emale participants accounted for 30%\u003c/strong\u003e. In terms of age (Fig. 2), most respondents were \u003cstrong\u003eunder 25 years old\u003c/strong\u003e, with the largest proportion falling between 20 and 25 years. Regarding current status, approximately \u003cstrong\u003e73% were ISPITS students\u003c/strong\u003e, while the remainder consisted of unemployed graduates or professionals engaged in further training.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eb Perceptions of Training and Professional Readiness\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eFindings highlight mixed perceptions of ISPITS training quality (Fig.\u0026nbsp;3). While some respondents considered the training satisfactory, a substantial proportion expressed concerns, emphasizing gaps in practical training and preparedness. Similarly, when asked whether graduates are able to practice without obstacles (Fig.\u0026nbsp;4), many respondents reported significant barriers, including insufficient practical exposure, limited supervision, and inadequate alignment between curricula and workplace requirements.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ec Professional Representation and Coordination\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMore than half of the respondents reported being members of the \u003cstrong\u003eNational Coordination of ISPITS Students and Graduates\u003c/strong\u003e. This widespread engagement underscores the perceived need for collective mobilization to address challenges related to training quality, professional integration, and employment opportunities.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ed Migration Intentions\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe survey revealed a strong inclination toward \u003cstrong\u003eprofessional migration\u003c/strong\u003e (Fig. 5). Nearly \u003cstrong\u003ethree-quarters (\u0026asymp;\u0026thinsp;73%)\u003c/strong\u003e of respondents reported planning to migrate abroad to practice their profession, while only 27% indicated no intention to leave. Preferred destinations included \u003cstrong\u003eEurope (notably Germany and France), North America (Canada, USA), and Gulf countries\u003c/strong\u003e. The main motivations cited were better recognition, improved working conditions, and higher salaries.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003e3.4. ISPITS and the Training of Health Professionals\u003c/h2\u003e\n \u003cp\u003eISPITS (Instituts Sup\u0026eacute;rieurs des Professions Infirmi\u0026egrave;res et Techniques de Sant\u0026eacute;) provide Bachelor-level education for nurses, midwives, and health technicians, playing a central role in developing Morocco\u0026rsquo;s health workforce. However, several studies have identified persistent gaps in their training programs. Curricula often insufficiently emphasize community health, disease prevention, and epidemiology, leaving graduates underprepared to address population health needs (Benbella et al., 2021). Pedagogical methods remain largely traditional, with limited use of formative assessments and innovative teaching strategies that cultivate critical thinking and practical skills (El Kharraz et al., 2023). Students also report feeling inadequately equipped to address social determinants of health, highlighting gaps in social accountability training (Idrissi et al., 2022). Moreover, despite the recognized potential of information and communication technologies (ICTs) to enhance learning and clinical practice, their integration into teaching remains minimal, limiting students\u0026rsquo; development of essential digital competencies for contemporary healthcare (Houssaini et al., 2021).\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDimension\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCurrent Status / Observation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eChallenges / Gaps\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eReferences\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCurriculum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBachelor-level education for nurses, midwives, and health technicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInsufficient emphasis on community health, disease prevention, and epidemiology; graduates underprepared for population health needs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBenbella et al., 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePedagogy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraditional teaching methods\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLimited use of formative assessments and innovative strategies; weak development of critical thinking and practical skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEl Kharraz et al., 2023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSocial Accountability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudents trained in health service delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFeeling inadequately equipped to address social determinants of health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIdrissi et al., 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDigital Integration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eICT recognized as potential tool for learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMinimal integration into teaching; limits digital competency development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHoussaini et al., 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003e3.5. Identified Gaps\u003c/h2\u003e\n \u003cp\u003eSeveral gaps have been identified in ISPITS training programs. First, the curricula show weak alignment with Morocco\u0026rsquo;s evolving epidemiological profile, which limits graduates\u0026rsquo; capacity to respond effectively to the country\u0026rsquo;s population health priorities. Second, students receive insufficient exposure to community-based learning and practical field experiences, reducing opportunities to develop hands-on competencies. Finally, limitations in educational infrastructure, supervisory support, and the integration of digital tools constrain both the quality of teaching and the acquisition of essential modern skills necessary for contemporary healthcare practice.\u003c/p\u003e\n \u003cp\u003eThe Fig.\u0026nbsp;6 illustrates the main areas where ISPITS training programs show limitations. Respondents and literature review highlighted four key gaps: insufficient integration of community health and prevention in the \u003cstrong\u003ecurriculum\u003c/strong\u003e, limited use of innovative methods in \u003cstrong\u003epedagogy\u003c/strong\u003e, lack of emphasis on \u003cstrong\u003esocial accountability\u003c/strong\u003e, and weak \u003cstrong\u003edigital integration\u003c/strong\u003e in teaching and practice.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study provides an exploratory analysis of public health challenges in Morocco, with a particular focus on the role of ISPITS in training human resources for health. By combining a narrative literature review with an exploratory survey, the findings highlight important gaps between current training programs and the evolving needs of the Moroccan health system.\u003c/p\u003e \u003cp\u003eThe literature review and survey results converge in identifying human resources for health as a major constraint affecting health system performance. Persistent shortages and unequal geographic distribution of nurses and midwives limit access to care, particularly in rural and underserved regions. These findings are consistent with previous studies that emphasize workforce availability as a critical determinant of healthcare quality and equity (Al Hassani et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA key contribution of this study lies in its analysis of training gaps within ISPITS programs. Both the literature and survey respondents point to insufficient emphasis on community health, disease prevention, and health promotion. This is particularly concerning in the context of Morocco\u0026rsquo;s epidemiological transition, where non-communicable diseases now represent a leading cause of morbidity and mortality (El Fakir et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Addressing NCDs effectively requires health professionals who are adequately prepared to engage in prevention, early detection, and long-term management at the community level.\u003c/p\u003e \u003cp\u003eIn addition, the findings reveal limitations in the development of competencies related to social determinants of health and social accountability. Students and graduates reported feeling insufficiently prepared to address broader population health needs, which may weaken the capacity of the health system to reduce health inequities. These observations align with international calls to strengthen the social accountability of health professional education in order to better respond to community and population health priorities (Frenk et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Idrissi et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother important gap concerns the integration of innovative pedagogical approaches and digital tools. Despite growing recognition of the role of digital health and simulation-based learning in improving training quality, their integration within ISPITS curricula remains limited. This may hinder the development of critical thinking, adaptability, and evidence-based practice among future health professionals, particularly in rapidly evolving healthcare environments (Houssaini et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; El Kharraz et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTaken together, these findings suggest that strengthening ISPITS training programs could play a key role in supporting Morocco\u0026rsquo;s progress toward universal health coverage. Aligning curricula more closely with national public health priorities, expanding community-based training opportunities, and enhancing pedagogical innovation could improve workforce preparedness and contribute to more resilient and equitable health services.\u003c/p\u003e \u003cp\u003eHowever, the findings of this study should be interpreted in light of its exploratory nature. While the results provide valuable insights into perceived training gaps, they do not allow for causal inferences or generalization to all health professionals in Morocco. Nevertheless, they offer a useful foundation for future, more robust research aimed at evaluating training reforms and their impact on public health outcomes.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003ePublic health in Morocco is at a critical juncture. While substantial progress has been made in expanding health coverage and improving access to care, persistent challenges related to health workforce availability, training, and equity continue to limit the overall performance of the health system. This study highlights the central role of the Instituts Sup\u0026eacute;rieurs des Professions Infirmi\u0026egrave;res et Techniques de Sant\u0026eacute; (ISPITS) in strengthening human resources for health and supporting national public health objectives.\u003c/p\u003e \u003cp\u003eThe findings from the literature review and the exploratory survey suggest that current ISPITS training programs may not be fully aligned with Morocco\u0026rsquo;s evolving public health needs. In particular, insufficient emphasis on community health, disease prevention, health promotion, and social accountability may limit graduates\u0026rsquo; capacity to effectively respond to the country\u0026rsquo;s epidemiological transition and to contribute to reducing health inequities. Strengthening these competencies, alongside greater integration of innovative pedagogical approaches and digital tools, could enhance workforce preparedness and resilience.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations of the study\u003c/b\u003e must be acknowledged. First, the exploratory and descriptive design does not allow for causal inference or generalization of the findings to all health professionals in Morocco. Second, the use of a convenience sampling strategy may introduce selection bias and limits representativeness. Third, the reliance on self-reported perceptions may be subject to response bias. Despite these limitations, the study provides valuable preliminary insights into perceived training gaps and workforce challenges.\u003c/p\u003e \u003cp\u003eFuture research should build on these findings by employing more robust study designs, including representative sampling and longitudinal approaches, to assess the impact of training reforms on health system performance and public health outcomes. Such research could contribute to evidence-based reforms in health professional education and support Morocco\u0026rsquo;s ongoing efforts to strengthen its public health system.\u003c/p\u003e"},{"header":"6. Critical appraisal of the robustness of the findings","content":"\u003cp\u003eThe findings of this study should be interpreted in light of several methodological considerations. First, the exploratory and descriptive design limits the ability to draw causal inferences or to generalize the results to all health professionals in Morocco. The study was designed to capture perceptions and emerging trends rather than to provide representative estimates or test predefined hypotheses.\u003c/p\u003e \u003cp\u003eSecond, the use of a convenience sampling strategy may have introduced selection bias, as participants who chose to respond may have had stronger opinions or specific experiences related to training and professional challenges. As a result, the perspectives captured in this study may not fully reflect the diversity of views across the entire health workforce.\u003c/p\u003e \u003cp\u003eThird, the reliance on self-reported data may be subject to response and social desirability biases. Participants\u0026rsquo; perceptions of training adequacy and professional readiness may not necessarily correspond to objective measures of competencies or performance. In addition, the statistical analysis was limited to descriptive indicators, without measures of variance or inferential testing, which further constrains the robustness of quantitative interpretations.\u003c/p\u003e \u003cp\u003eDespite these limitations, the convergence between findings from the literature review and the exploratory survey strengthens the internal coherence of the results. The consistency of identified training gaps across multiple sources suggests that the issues highlighted are relevant and warrant further investigation. As such, the findings should be viewed as \u003cb\u003epreliminary but informative\u003c/b\u003e, providing a foundation for future studies using more rigorous and representative designs.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e \u003cb\u003eFunding Declaration\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eThis research did not receive any specific grant or funding from public, commercial, or not-for-profit sectors.\u003c/p\u003e \u003cp\u003eWe confirm that the manuscript is original, has not been published elsewhere, and is not under consideration by any other journal. All authors have read and approved the final version of the manuscript.\u003c/p\u003e \u003cp\u003e \u003cb\u003eHuman Ethics and Consent to Participate declarations\u003c/b\u003e :\u003c/p\u003e \u003cp\u003eThe study was conducted in accordance with the ethical principles outlined in the \u003cb\u003eDeclaration of Helsinki\u003c/b\u003e. Participation was voluntary, and informed consent was obtained from all participants prior to data collection. No personal identifiers were collected, and all data were analyzed anonymously.\u003c/p\u003e \u003cp\u003eAccording to institutional regulations, formal ethical committee approval was not required for anonymous, non-interventional surveys involving adult participants. This clarification has been explicitly included to ensure transparency and consistency between the manuscript and the annexes.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to Publish \u003cb\u003edeclaration\u003c/b\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAbdelkarim Taam: The corresponding author responsible for ensuring that the descriptions are accurate and agreed by all authors. Visualization, Formal analysis, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing.Salah-Eddine Laariny : Visualization, Formal analysis, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to institutional restrictions and the protection of participant confidentiality, but are available from the corresponding author on reasonable request.All anonymized survey data are securely stored at the Faculty of Letters and Human Sciences, Sidi Mohamed Ben Abdellah University, Fez, Morocco.Requests for access to the data should be directed to the corresponding author at **[email protected]** .\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAl Hassani A, Achhab Y, Nejjar S, et al. Challenges faced by human resources for health in Morocco: A scoping review. PLoS ONE. 2024;19(4):e0312345. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0312345\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0312345\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenbella A, et al. Learning strategies in nursing sciences: Analysis of gender disparities among first-year students. Educaci\u0026oacute;n M\u0026eacute;dica. 2021;22(4):212\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.edumed.2021.05.006\u003c/span\u003e\u003cspan address=\"10.1016/j.edumed.2021.05.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBennis I, et al. Moroccan digital health response to the COVID-19 crisis. Front Public Health. 2023;11:118765. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpubh.2023.118765\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2023.118765\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCreswell JW, Plano Clark VL. Designing and conducting mixed methods research. 3rd ed. Sage; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl Fakir S, et al. Non-communicable diseases in Morocco: Current situation and perspectives. Int J Public Health. 2022;67:1604093. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/ijph.2022.1604093\u003c/span\u003e\u003cspan address=\"10.3389/ijph.2022.1604093\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl Kharraz A et al. (2023). Formative assessment practices in ISPITS curricula: Between prescribed and actual practices. E3S Web of Conferences, 412, 01043. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1051/e3sconf/202341201043\u003c/span\u003e\u003cspan address=\"10.1051/e3sconf/202341201043\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEtikan I, Musa SA, Alkassim RS. Comparison of convenience sampling and purposive sampling. Am J Theoretical Appl Stat. 2016;5(1):1\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923\u0026ndash;58. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0140-6736(10)61854-5\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(10)61854-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreen BN, Johnson CD, Adams A. Writing narrative literature reviews for peer-reviewed journals. J Chiropr Med. 2006;5(3):101\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoussaini H, et al. Integration of information and communication technologies in nursing education: The case of ISPITS Morocco. J Nurs Educ Pract. 2021;11(6):45\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5430/jnep.v11n6p45\u003c/span\u003e\u003cspan address=\"10.5430/jnep.v11n6p45\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIdrissi K, et al. The social accountability of nursing training institutes in Morocco: Perceptions and realities. J Adv Med Educ Professionalism. 2022;10(2):75\u0026ndash;83. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.30476/jamp.2022.90234.1635\u003c/span\u003e\u003cspan address=\"10.30476/jamp.2022.90234.1635\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSetia MS. Methodology series module 3: Cross-sectional studies. Indian J Dermatology. 2016;61(3):261\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZouine A, et al. Assessment of patient safety culture in Moroccan primary health care: A multicenter cross-sectional study. BMC Nurs. 2024;23:186. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12912-024-01864-6\u003c/span\u003e\u003cspan address=\"10.1186/s12912-024-01864-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Morocco, public health, ISPITS, nursing education, health system, human resources for health","lastPublishedDoi":"10.21203/rs.3.rs-7794361/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7794361/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMorocco has undertaken significant reforms in its health system, particularly in expanding health coverage and investing in the training of health professionals through the \u003cem\u003eInstituts Sup\u0026eacute;rieurs des Professions Infirmi\u0026egrave;res et Techniques de Sant\u0026eacute;\u003c/em\u003e (ISPITS). Despite these advances, persistent challenges remain regarding equity, quality of care, and the adequacy of training to meet public health needs. This article reviews the literature on public health in Morocco, analyzes the challenges of the national health system, and explores the contribution of ISPITS to preparing a competent workforce. Findings indicate a mismatch between ISPITS curricula and national public health priorities, especially in prevention, health promotion, and community health. Recommendations are provided for curricular reforms, digital integration, and strengthening social accountability.\u003c/p\u003e","manuscriptTitle":"Public Health in Morocco: National Context, Health System Challenges, and the Role of ISPITS in Training Human Resources for Health","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-23 18:39:48","doi":"10.21203/rs.3.rs-7794361/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"20079b29-8d9a-493c-b0b1-2c89528fb414","owner":[],"postedDate":"January 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-23T18:39:48+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-23 18:39:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7794361","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7794361","identity":"rs-7794361","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}