The role of social protection in Africa Mary Amuyunzu-Nyamongo, Alice Sinkeet and Brenda Maina Commonwealth Health Partnerships 2015 103 There is a growing global awareness that the world is ageing. It is projected that people aged 60 years and over will constitute two billion of the world’s population by 2050. In Africa the population of older people is expected to grow from 46 million in 2015 to 157 million by 2050, with this growth occurring in a context where health care is constrained by accessibility, quality of care and affordability. The situation is dire for older people, most of whom have limited access to health insurance and family support. Poor people, who have been unable to save for old age, are particularly vulnerable. This article presents an analysis of the current status of health care access for older people in African countries with a call for universal health coverage (UHC). Ageing and health status Older people (those aged 60 years and above) in Africa face a large morbidity and disability burden, particularly from chronic diseases. The World Health Organization (WHO) Global Burden of Disease report 20101 indicates that cardiovascular and circulatory diseases, nutritional deficiencies, cirrhosis of the liver and diabetes are the major causes of disability-adjusted life years for Sub-Saharan Africa’s older population. The results of a WHO (2012) study established that the most commonly reported health problems facing older people were arthritis (42 per cent), hypertension (41.3 per cent), malaria (35.9 per cent) and eye problems (35.9 per cent). Further, infectious diseases continue to affect older people in Africa within a context of high levels of HIV among other infectious and neglected tropical diseases (such as trachoma and onchocerciasis). The susceptibility of older men and women to ill health has farreaching effects since they make critical contributions to their households and communities throughout the continent. It is notable that across the continent 64 per cent of men over 60 years of age continue to work across the formal and informal sectors. Furthermore, older women tend to live longer than older men, with a life expectancy at 60 of a further 17 years.2 In fact, in most communities, and more so in rural areas, older women continue in their domestic and subsistence farming roles. Consequently, impaired health in older age does not only affect the older people in Africa, but overall prospects for development. There is evidence that the health systems in Africa are structured to respond more to acute illnesses, and child and maternal health rather than to the needs of older people. Despite having worse health than younger age groups, older people in Sub-Saharan Africa have been observed to use health services substantially less than younger people (McIntyre, 2004). The limited use of health facilities by older people could be due to several factors, including being unable to pay for transport to get to the health centre or for the medication; lack of the right identity documentation to prove their eligibility for free or subsidised services; being unaware of what they are entitled to; being physically unable to queue for a long time while waiting to be seen, or to take the journey to the health centre by public transport; and being geographically isolated from services, with limited or a complete lack of public transport, as is the case in some sub-regions on the continent.3 The state of health insurance It is evident that few countries in Africa provide public health care services free of charge – these are Algeria, Egypt, Ghana, Libya, Mauritius, Morocco, Rwanda, South Africa and Tunisia. Only three of the ten countries participating in the WHO-AFRO report (2012) had formal health insurance (Algeria, Cameroon and South Africa). The majority of the respondents in the three sub-regions did not have health insurance and had limited reimbursement of the money spent on treatment. In Central Africa about 12 per cent of the respondents had health insurance; in East and Southern Africa, 9.1 per cent; and in West Africa, 2.5 per cent. In the Central African Republic, study participants reported that the government, with resources from development partners, provided subsidies, while in Senegal the model was based on community financing. Exceptionally, in Algeria insurance companies provided 99.3 per cent reimbursement for the cost of medicine for those in rural areas, 96.4 per cent for those in urban areas and 98.9 per cent for those in peri-urban areas. The overall proportion of the respondents who had free government health services was less than 14 per cent. To ease the burden of health care for vulnerable persons, including the poor and the elderly, some countries have initiated waiver systems for particular health conditions. However, exemptions and waivers that are not obtained as health insurance remain at the rudimentary stages of development in the region. In countries where user fees are charged, there is limited evidence that quality of care has improved even with the additional funds generated from such fees. There is a possibility that people often delay or defer accessing or using services even if they believe they need care, due to high out-of-pocket payments (Peltzer et al., 2014). One strategy being used by some African countries, although mostly on a pilot basis, is the introduction of old age pensions that are either targeted (e.g. in Kenya and Tanzania) or universal (e.g. in Lesotho and Mauritius). The cash transfers support the older persons in meeting their health care and food needs, among other requirements. In Lesotho, for instance, Anotsi and Aiyuk (2012) established that ‘with the initiation of monthly pension they older people were able to access health services and also had some money to spare … the pension money had contributed to the ability of the elderly to pay for health services and to access health care’. In Ghana there are efforts to link the cash transfers to the national health insurance scheme. In addition, Kenya is in the
Commonwealth Health Partnerships 2015
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