Article Text

How medical dominance and interprofessional conflicts undermine patient-centred care in hospitals: historical analysis and multiple embedded case study in Morocco
  1. Zakaria Belrhiti1,
  2. Sara Van Belle2,
  3. Bart Criel3
  1. 1Ecole Nationale de Santé Publique, Rabat, Morocco
  2. 2Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
  3. 3Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
  1. Correspondence to Dr Zakaria Belrhiti; drbelrhiti{at}


Background In Morocco’s health systems, reforms were accompanied by increased tensions among doctors, nurses and health managers, poor interprofessional collaboration and counterproductive power struggles. However, little attention has focused on the processes underlying these interprofessional conflicts and their nature. Here, we explored the perspective of health workers and managers in four Moroccan hospitals.

Methods We adopted a multiple embedded case study design and conducted 68 interviews, 8 focus group discussions and 11 group discussions with doctors, nurses, administrators and health managers at different organisational levels. We analysed what health workers (doctors and nurses) and health managers said about their sources of power, perceived roles and relationships with other healthcare professions. For our iterative qualitative data analysis, we coded all data sources using NVivo V.11 software and carried out thematic analysis using the concepts of ‘negotiated order’ and the four worldviews. For context, we used historical analysis to trace the development of medical and nursing professions during the colonial and postcolonial eras in Morocco.

Results Our findings highlight professional hierarchies that counterbalance the power of formal hierarchies. Interprofessional interactions in Moroccan hospitals are marked by conflicts, power struggles and daily negotiated orders that may not serve the best interests of patients. The results confirm the dominance of medical specialists occupying the top of the professional hierarchy pyramid, as perceived at all levels in the four hospitals. In addition, health managers, lacking institutional backing, resources and decision spaces, often must rely on soft power when dealing with health workers to ensure smooth collaboration in care.

Conclusion The stratified order of care professions creates hierarchical professional boundaries in Moroccan hospitals, leading to partitioning of care and poor interprofessional collaboration. More attention should be placed on empowering health workers in delivering quality care by ensuring smooth interprofessional collaboration.

  • health services research
  • qualitative study
  • hospital-based study
  • health systems

Data availability statement

Data sharing is not applicable as no data sets were generated and/or analysed for this study.

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Data availability statement

Data sharing is not applicable as no data sets were generated and/or analysed for this study.

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  • Handling editor Seye Abimbola

  • Twitter @drbelrhiti

  • Contributors All three authors contributed to the original design and analysis and writing of the manuscript. ZB carried out the data collection. SVB and BC revised the different versions of the manuscript. ZB edited the final draft. All authors read and approved the final manuscript.

  • Funding The PhD work of which this study is a part was funded through a PhD framework agreement between the Belgian Directorate-General for Development Cooperation and the Institute of Tropical Medicine, Antwerp.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.