In the context of Morocco’s expansion of social protection, the governance of the health insurance system faces structural tension. Decision-makers must navigate trade-offs between the financial sustainability of insurance schemes and the social mission of ensuring equitable access to care, giving rise to major ethical dilemmas.

This article analyzes ethical decision-making as a lever for the governance of health insurance in Morocco. It examines the ethical challenges involved, identifies the factors influencing decision-makers, and explores how the integration of ethical principles can enhance equity and sustainability within the system.

A qualitative study was conducted using in-depth documentary analysis. The corpus included legislative texts, institutional reports (from ANAM, CNSS, etc.), and academic publications from 2002 to 2023. Data were analyzed thematically, and the validity of the findings was strengthened through source triangulation.

The findings reveal a governance system under strain, characterized by a central dilemma between equity and efficiency. Four categories of risk factors for unethical decision-making were identified: human, financial, political, and regulatory. Such decisions have systemic consequences, including erosion of trust among the insured, reduced system efficiency, and the widening of inequalities.

Ethical decision-making is not optional but a necessary condition for the success of Morocco’s social protection expansion. It represents a fundamental lever for strengthening governance, aligning actions with the public interest, and fostering trust, thereby contributing to a more equitable, effective, and sustainable health insurance system.