Although the population of older people in Africa is increasing, and older people are becoming increasingly vulnerable due to urbanisation, breakdown of family structures and rising healthcare costs, most African countries have no social health protection for older people. Two exceptions include Senegal's Plan Sesame, a user fees exemption for older people and Ghana's National Health Insurance Scheme (NHIS) where older people are exempt from paying premiums. Evidence on whether older people are aware of and enrolling in these schemes is however lacking. We aim to fill this gap. Besides exploring economic indicators, we also investigate whether social exclusion determines enrolment of older people. This is the first study that tries to explore the social, political, economic and cultural (SPEC) dimensions of social exclusion in the context of social health protection programs for older people. Data were collected by two cross-sectional household surveys conducted in Ghana and Senegal in 2012. We develop SPEC indices and conduct logistic regressions to study the determinants of enrolment. Our results indicate that older people vulnerable to social exclusion in all SPEC dimensions are less likely to enrol in Plan Sesame and those that are vulnerable in the political dimension are less likely to enrol in NHIS. Efforts should be taken to specifically enrol older people in rural areas, ethnic minorities, women and those isolated due to a lack of social support. Consideration should also be paid to modify scheme features such as eliminating the registration fee for older people in NHIS and creating administration offices for ID cards in remote communities in Senegal.
In their ‘manifesto for the world we want’, The Lancet (2012) identified globally ageing population as a critical issue that must be addressed to help create sustainable improvements in health. By 2016 it is estimated that there will be more people older than 65 years than children under five, and 1.5 billion people over 60 will be added to the global population between now and 2050 (UN, 2009). Despite the demographic transition being more advanced in developed countries, between 1950 and 2000, 66% of the global increase in people over 60 occurred in low- and middle-income countries (LMIC); by 2050 it is projected that 80% of all older people (i.e. 1.6 billion) will be living in LMIC (Aboderin, 2012 and Beard et al., 2011, pp. 4). This unprecedented and rapid demographic shift will have far-reaching consequences for health systems and many LMIC already face immense challenges in providing adequate, age-appropriate healthcare and a decent standard of living for older people.
In Sub-Saharan Africa (SSA) the issue of ageing has so far received little attention from both policy makers and researchers. However, in spite of the low relative share of older people in the total SSA populations (below 10%); the subcontinent still hosts a significant aged population, which is expected to grow at a steady pace. With life expectancy of 16 years for 60 year olds, getting old is no longer an exception in Africa.
Ageing in Africa raises particular concerns because of its strong association with increased vulnerability. Several risk factors are associated with this heightened vulnerability (Crooks, 2009 and Issahaku and Neysmith, 2013). First, older people in SSA usually retire in rural areas, characterized by poor infrastructures and acute problems of basic service provision. Second, many scholars point out the feminisation of the SSA aged population – ‘a female society’ according to Apt (2009). This makes Africa's older women twice as vulnerable, first due to the biological process of ageing, and, second, due to gender-related discrimination. Third, majority of older people are illiterate (67% in Africa (UN, 2009)), which is associated with poor access to public resources. Furthermore, most of the Africa's older people, especially women, have no formal employment records and thus no access to formal social security arrangements like pensions. It is estimated that only 17% of older people in SSA receive an old-age pension (International Labour Organization, 2014).
Historically the extended family structure in Africa has mitigated the effect of these combined risk factors. However, evidence suggests the situation is changing. Traditional respect and caring structures are facing substantial social challenges, hence refuting the widespread African myth of the “inexhaustible capacity of the extended family to withstand crisis” (Gysels et al., 2011).
Access to appropriate healthcare remains a major concern for the majority of the ageing population in SSA. Facts speak for themselves: not only do older people spend more per-capita on healthcare than others in LMIC, consequently bearing a heavy burden linked to user fees policies, they also face higher levels of unmet need for healthcare, with a greater proportion of older people reporting forgone treatments for illness than younger groups (McIntyre, 2004 and Saeed et al., 2012). The gap between needs and access is expected to grow further in the short term, especially due to the escalating epidemic of non-communicable diseases (NCDs) among the ageing population (Alam et al., 2010, George-Carey et al., 2012 and Holmes and Joseph, 2011).
Recognising the increased vulnerability of older people in relation to illness and healthcare expenditures, two West African countries, Ghana and Senegal, have implemented Social Health Protection (SHP) programs that specifically target older people. These programs aim to reduce the financial barriers faced by older people in accessing healthcare services.
Our study makes a valuable contribution to the evaluation of SHP for older people in LMIC. Plan Sesame and exemptions for older people in NHIS are both significant policies that have taken steps to address the inequities experienced by older people in relation to healthcare access. However, results from our study indicate that older people at risk of social exclusion are currently disadvantaged in enrolment and neither scheme has yet achieved the goal of equity in access for older people. Although these schemes aim to reduce financial barriers to enrolment, economically vulnerable persons still suffer from inequities in enrolment and efforts should be taken to identify the very poorest to ensure they are aware of and enrol in SHP schemes. Simply targeting the removal or reduction of financial barriers may not be enough. Enhanced efforts should also be made to reach older populations in remote areas, those who belong to ethnic minorities, women, and those isolated due to a lack of social support. Consideration should also be paid to modifying scheme features such as eliminating the registration fee for older people in NHIS and creating administration offices for ID cards in remote communities in Senegal. Recognising and taking steps to address factors hindering enrolment of older people at risk of social exclusion will ultimately improve the prospect of achieving equity and universal coverage in older populations.
