ghana's eldelry population incresed seven fold in last six decades how does policies for elderly work there

1. POLICIES FOR ELDERLY IN
GHANA
VIDDYANSH SRIVASTAVA
PRACHI POWAR
BIKRAM BARMAN
GANA P
IIPS MUMBAI

3. DEMOGRAPHY PROFILE
• TOTAL POPULATION – 24,200,000 (2010 census) (49th)
• Population growth rate – 2.18%
• Area - 238,533 km² (80th)
• Population density - 101.5/km2 (103rd)
• Median age – 21.1 years
• Birth rate - 30.5 births/1,000 population (2017 est.)
• Death rate - 7 deaths/1,000 population

4. • Sex ratio - 0.97 male(s)/female (2016 est.)
• Infant mortality rate: 35.2 deaths/1,000 live births
• Life expectancy at birth: 67 years
• TFR – 3.87 children born/woman (2017 est.)
• Religions: Christian 71.2% , Muslim 17.6%, traditional 5.2%,
other 0.8%, none 5.2%
• Literacy rate : 76.6%

5. Age structure
0-14 years: 38.01%
15-24 years: 18.63%
25-54 years: 34.14%
55-64 years: 4.97%
65 years and over: 4.25%

6. Dependency ratios
total dependency ratio: 73
youth dependency ratio: 67.1
elderly dependency ratio: 5.9
potential support ratio: 17.1 (2015 est.)

7. Source: Ghana Statistical Service, Census Report

8. POPULATION AGEING
SITUATION IN GHANA
• there has been a sevenfold increase in the population of
the aged from 215,258 in 1960 to 1,643,978 in 2010
• Currently proportion of older person is 6.7%
• female elderly population is 56 per cent compared with
44 per cent for males
• More than a tenth (12.3%) of the elderly has one or more
kinds of
• disability
• even though Ghana’s population remains largely youthful
but the size of the elderly population has been growing

9. Implications of Population
Ageing
• A growing population of older persons comes with an
increase in degenerative and non-communicable
diseases
• affect the size and composition of its labour force, their
participation in economic activities as well as the
economic growth of the country
• Sustaining Social Security Issues
• older persons in Ghana, particularly women are more
likely to depend on others, given lower literacy and
higher incidence of widowhood.

10. ECONOMIC AND HEALTH
OVERVIEW
• Ghana has a market-based economy with 8.7% GDP growth in
2012
• Agriculture accounts for about 20% of GDP and employs more
than half of the workforce
• 5.2% of Ghana's GDP was spent on health in 2010
• There are over 200 hospital and 0.1 physicians per 1,000
people and as of 2011, 0.9 hospital beds per 1,000 people
• over 12 million Ghanaian nationals were covered by
the National Health Insurance Scheme

11. Available Health System Policies

12. Most common disease in Ghana:
• Musculoskeletal conditions: Musculoskeletal conditions are a major
burden on individuals, health systems and social care systems, with indirect
costs being the predominant factor. Arthritis was self-reported in the SAGE
study by 13.8% of the people surveyed, and more commonly by women,
who had greater access to current as well as chronic ongoing therapy for
arthritis than men. The rates of both self-reported arthritis and symptom-
based assessment increased with age, with the highest among the ≥ 80
years age group.
• Diabetes: Diabetes was self-reported by 3.8% of respondents and 76.3%
received current treatment, while 80.4% were in chronic ongoing therapy.
Women had higher rates of diabetes than men, but men received both
current and chronic ongoing therapy at a higher rate than women. Diabetes
was self-reported more by the urban than rural aged, with urban-based
older people receiving higher levels of both current and chronic ongoing
therapy (Biritwum et al., 2013).

13. • Respiratory problems: Chronic lung disease was self-reported by 0.6% of the
people whose data were analyzed, with men receiving more current and chronic
ongoing therapy than women. More urban residents self-reported than rural
residents. Chronic lung disease was reported more frequently by the highest
income quintiles and they received the highest current and chronic ongoing
therapy; there was no clear pattern among the other wealth quintiles (Biritwum
et al., 2013). Asthma prevalence, based on self-reporting, was 3.3%, and was
3.7% based on reported symptoms. It was almost equally reported by women
and men, but women received a higher rate of current and chronic ongoing
therapy. Asthma was also self-reported almost equally by the urban and rural
older populations but, in urban areas, older people received more current and
chronic ongoing treatment than the rural aged.
• Heart disease and related conditions: Stroke was self-reported by 2.8% of
respondents, almost equally by women and men. However, more women
received both current and chronic ongoing therapy than men. The ≥ 80 years
age group had the lowest levels of current (35.2%) and chronic ongoing (50%)
therapy compared to the 50–59 years age group (45.9% and 69.4%,
respectively). Stroke was self-reported more frequently by the urban (4.3%)
than the rural (1.7%) aged, where they received higher levels of both current
and chronic ongoing therapy – probably because the urban-based aged were
more aware and had better access to health facilities.

15. Background:
• Health care financing in Ghana began with a tax-funded system
that provided free public health care services to all after
independence. As this system gradually became financially
unsustainable with economic stagnation in the 1970s, initially low
user fees were established for hospital services to discourage
unnecessary use, locally recover some costs and generate provider
performance incentives. Continued declines in government
spending on health through the 1970s and 1980s led to shortages
of medicines and supplies and deteriorating quality of care.
• Following adoption of structural adjustment reforms in 1983, the
Rawlings administration raised and expanded user fees for public
health care services in a system that became known as “cash and
carry.” The user fee system improved operating revenues for some
facilities, but it was poorly regulated, inconsistently implemented,
and found to have worsened access to care for the poor.

16. • Starting from the early 1990s, Ghana began to seek other ways of
financing health care, including NGO-initiated community-based health
insurance schemes (CBHIS). While popular among members and
international donors at the time, the schemes were only targeted to
specific areas, failed to address key social insurance issues, and were
not supported by general government revenue to allow them to cater for
the poor. Most importantly, with CBHIS covering only about 1% of the
population with limited benefit packages, the system of user fees
remained the predominant means of paying for health care.
• The highly unpopular “cash and carry” system became a salient
political issue and the main opposition party, the National Patriotic
Party (NPP), began to call for its abolishment in its manifestos and
campaigns—a promise that may have helped the NPP win the 2000
presidential and parliamentary elections.
• Ultimately, the National Health Insurance Scheme (NHIS) was
established under Act 650 of 2003 by the Government of Ghana to
provide a broad range of health care services to people of Ghana
through district mutual and private health insurance schemes.

17. Health service delivery
• The health sector in Ghana is both public and private. The public sector
is run by the Ghana Health Service (GHS) and teaching hospitals.
Ghana has three teaching hospitals providing tertiary care and training
for doctors. The private sector is made up of faith-based and private-
for-profit health institutions.
• The GHS is an integrated three-tier health delivery system of primary,
secondary and tertiary levels. At the primary level, a district hospital
with a medical doctor serves health centers in sub-districts with
physician assistants in charge. In some sub-districts there are
community health planning and services (CHPS) zones where
community health officers work with community volunteers to increase
access to health care. A typical district with a population of 100 000 has
1 hospital, 5 health centers and 10–15 CHPS zones. At the secondary
level there is a regional hospital that provides secondary care and is run
by general practitioners and specialists. There are ten regional hospitals
receiving referrals from the districts and providing outreach support.

18. The Ghana National Health Insurance
Scheme:
• Ghana's National Health Insurance Scheme (NHIS) was created by the
National Health Insurance Act of August 2003, and is one of very few
attempts by a sub-Saharan African country to implement a national-level,
universal health insurance program.
• A newly-created National Health Insurance Authority (NHIA) was
commissioned “to secure the implementation of a national health insurance
policy that ensures access to basic healthcare services to all residents.”
• The NHIS is financed from four main sources: a value-added tax on goods
and services, an earmarked portion of social security taxes from formal
sector workers, individual premiums, and miscellaneous other funds from
investment returns, Parliament, or donors. The 2.5 per cent tax on goods
and services, called the National Health Insurance Levy (NHIL), is by far
the largest source, comprising about 70 per cent of revenues. Social
security taxes account for an additional 23 per cent, premiums for about 5
per cent, and other funds for the remaining two per cent.

19. • The NHIS covers outpatient services, including diagnostic testing and
operations such as hernia repair; most in-patient services, including
specialist care, most surgeries, and hospital accommodation (general ward);
oral health treatments; all maternity care services, including Caesarean
deliveries; emergency care; and, finally, all drugs on the centrally-
established NHIA Medicines List.
• The NHIS package excludes some very expensive procedures such as
certain surgeries, cancer treatments (other than breast and cervical cancer),
organ transplants, and dialysis; non-vital services such as cosmetic surgery;
and some high profile items such as HIV antiretroviral drugs (which are
heavily subsidized by the separate National AIDS Program).

20. The private sector in Ghana is relatively active in the provision of
health care, including to older people. The number and proportion of
public/private health-care facilities providing specialist geriatric care is
not known and there is a need for such a mapping exercise. There are
several NGOs that play a key role in health care, including to older
people. Examples include:
• Christian Health Association of Ghana (CHAG) – whose goal is to
improve the health status of population of Ghana, especially the
marginalized and poorest of the poor – is the second largest provider
of health services in the country. It is estimated that approximately
42% of total health services in the country are provided by CHAG
member institutions.
• HelpAge Ghana is the main organization that promotes the prospects
of older people in Ghana. Its missions are to advance the interests
and welfare of older people in the country regardless of their sex,
creed and colour; provide leadership in ageing policy development
and implementation; and promote the rights and well-being of older
people.

21. • Ageing as a policy issue received international
recognition at the first World Assembly on Ageing held in
Vienna, Austria in 1982 to address ageing concerns and its
implications for national development.
• Since then several ageing-related conferences have been
held including the 1984 International Conference on
Population and Development,
21

22. National ageing policy, July 2010
‘Ageing with security and dignity’
• The Policy Document and the Implementation Action Plan
were approved by Cabinet on 29th October, 2010.
• The draft national policy on ageing prepared in 2002 had not
been implemented for several reasons including absence of
implementation action plan and the apparent lack of ownership
by older persons who are the primary stakeholders.
• Several factors affecting older persons have since changed and
the approach for developing ageing policies to achieve
sustainability of implementation has also changed. 22

23. Objectives and Principles of the National Ageing Policy
• To achieve the overall social, economic and cultural re-
integration of older persons into mainstream society, to enable
them as far as practicable to participate fully in the national
development process.
• In the pursuit of this goal full recognition will be given to their
fundamental human rights including the right to independence,
active participation in society, benefit from community support
and care, self-fulfillment in pursuit of educational and other
opportunities and dignity, security and freedom from
23

24. Challenges of National Ageing Policy
The demographic dynamics point to a rapidly increasing population
of older persons within a period of social and economic challenges
with respect to delivery of health services, housing, transportation,
social protection and other services which are generally expensive
to obtain but which are needed by older persons to improve their
standard of living.
• Demographic dynamics of ageing
• Ageing and fundamental human rights
• Ageing and the development challenge
• Ageing and poverty
 Old age and health
challenges
 Ageing and the living
environment
 Ageing and gender
24

25. The policies and strategies that promoted and pursued by
government to improve the living standards of older persons in
Ghana include:
• Upholding the Fundamental Human Rights of Older Persons
• Ensuring Active Participation of Older Persons in Society and
Development
• Reducing Poverty among Older Persons
• Improving Health, Nutrition and Well-Being of Older Persons
• Improving Housing and Living Environment of Older Persons
25

26. • Improving Income Security and Enhanced Social Welfare for
Older persons
• Providing Adequate Attention to Gender Variations in Ageing
• Strengthening Research, Information Gathering and Processing,
and Coordination and Management of Data on Older Persons
• Enhancing Capacity to Formulate, Implement, Monitor and
Evaluate Policies on Ageing
• Improving Financing Strategies to Ensure Sustainability of
Implementation of Policies and Programmes of Older Persons.
26

27. Policy to Practice - National Ageing Policy
• In 2010, the Government of Ghana approved a national policy
on ageing. Two years later, it asked WHO to support it in
moving from policy to practice.
• WHO’s first step was to set up a multi-stakeholder task team on
ageing and health.
• The team was made up of staff from the Ministry of Health, the
Ministry of Gender, Children and Social Protection, the Ghana
Health Service, the University of Ghana, the United Nations
Population Fund (UNFPA), and nongovernmental organizations
such as HelpAge and Alzheimer’s Ghana.
27

28. • The team reviewed all the research that was available on
ageing in Ghana. Some key data came from the WHO
Study on global AGEing and adult health (SAGE), a
project that is collecting comprehensive information on the
status and health needs of older people in six low- and
middle-income countries.
• In Ghana, the SAGE study interviewed over 4000 people
aged 50 and above. They provided information on their
household, social and economic circumstances, health
behaviours, diagnosis and treatment of chronic conditions,
and access to health services. Their height and weight were
28

29. • The task team identified five priority areas for action. These
covered prevention and treatment of disease as well as
improvements to the health system:
 undiagnosed and untreated hypertension
 difficulties in carrying out everyday tasks and social
isolation
 poor utilization of health services
 inadequate preparedness of the health workforce to
care for older people
 undetected and/or unmanaged problems with eyesight
and hearing loss.
29

30. • The task team drew up concrete recommendations for
addressing priority areas.
• The recommendations ranged from community sensitization
and improving health workers’ ability to deal with the needs
of the elderly, to broadening coverage of national health
insurance schemes and making hearing devices and eye
glasses available to people who need them.
• The task team’s recommendations have been taken up in
Ghana’s Medium Term Health Strategy for 2014-2017.
30

31. Growth and Poverty Reduction Strategy (GPRS II) (2006 –
2009)
• Section 4.8 of the GPRS II provides the social policy framework
for mainstreaming the vulnerable and excluded in human
resource development.
• It recognizes that a significant proportion of Ghanaians including
the elderly, women and persons with disabilities, etc. either do
not reach their full human potential or cannot contribute
effectively to economic growth and sustainable social
development due to vulnerability and exclusion.
31

32. Social Protection Strategy
• Ghana has developed a National Social Protection Strategy
(NSPS) to enhance the capacity of poor and vulnerable persons
by assisting them to manage socio-economic risks, such as
unemployment, sickness, disability and old age.
• To increase the livelihoods of target groups by reducing the
impact of various risks and shocks that adversely affect income
levels and opportunities to acquire sustainable basic needs.
• The strategy draws attention to the need to take a collaborative
and innovative approach to provide social empowerment
initiatives to improve the livelihoods of poverty stricken32

33. • The strategy further suggests ways of ensuring that social
protection plays a key role in improving health and education
outcomes and provides strategies to prevent income loss, old
age insecurity pension) and skills development both for the
formal and informal sectors.
33

34. Persons with Disability Act, 2006 (Act 715)
• The Persons with Disability (PWD) Act though not age-
specific provides relevant contextual information that should
help improve the condition and well-being of older persons.
The law provides for the rights of persons with disability
including:
i) right to family life and social activities;
ii) right to equal treatment in respect of housing/residence;
iii) right to decent living conditions and environment;
iv) non-discrimination and exploitation of PWD and improved
34

35. • The Act also provides for employment support. It provides
tax incentives to employers who engage PWD. It also makes
provisions for training, rehabilitation including community-
based rehabilitation and the provision of working tools and
appropriate facilities to enable PWD function well at the
place of work. Additionally, provisions have been made
under the law to improve transportation and health-care
needs of older persons.
35

36. Livelihood Empowerment Against Poverty (LEAP)
• Under this programme, extremely poor households in Ghana
are given conditional and unconditional cash transfer on bi-
monthly basis. The cash transfer is expected to insulate
beneficiaries from the livelihood shocks and enhance their
access to basic social services like health and education.
• Old age is a criterion for targeting and benefitting from the
programme. Older Persons 65 years and above without
productive capacity are eligible to be covered. 36

37. National Health Insurance Scheme (NHIS)
• Older Person 70 years and above are covered by the National
Health Insurance Scheme without payment of premium. This is
to ensure increased access to health care for Older Persons in
Ghana. The major challenge with the NHIS is that Older
Persons 65 years and above but less than 70 years join the
scheme by payment of premium.
National Pension Scheme
• There is a three-tier pension system. The system was developed
to capture the 84 per cent informal economy in Ghana, where
majority of Older Persons operate.
37

38. • The non-mandatory component targets the informal Economy
so that operatives (potential Older Persons) may contribute a
proportion of their income towards old Age. A combination of
two tiers which form the third tier is aimed at increasing
pension allowances during retirement as contributors make
involuntary contribution in addition to their mandatory
contributions.
• It is however important to note that, the programmes above are
social protection programmes targeting the poor without
special attention to the perculiar needs of Older Persons. 38

39. The Persons with Disabilities Act (2006)
• Though not age-specific, also provides relevant contextual
information that should help improve the circumstances and
well-being of older people.
• For example, the law provides for the rights of people with
disabilities to equal treatment in respect of housing/residence,
non-discrimination and exploitation, and improved access to
public places.
• The Act also provides for employment support and tax
incentives to employers, and provisions for training and
appropriate facilities at workplaces. 39

40. THE NATIONAL COUNCIL ON AGEING
• Given the multi-faceted, multi-dimensional and multi-sectoral
nature of ageing issues, there is the need to establish a
coordinating body to oversee the networking arrangements and
effectively coordinate institutional commitments required for
the successful implementation of the National Ageing policy.
• Accordingly, the Government in collaboration with stakeholders
will establish the National Council on Ageing (NCA). The
Council will be a national body that will guide the
implementation of the National Ageing Policy. It will issue
40

41. The National Population Policy, Revised Edition, 1994 also
recognizes older persons as an important segment of the
population of Ghana and outlines actions to promote their full
integration into all aspects of national life through advocacy,
enactment of laws and collaboration between all stakeholders.
41

42. Gana

43. Recommendations for Way Forward
The key ministries responsible for ageing are
Ministry for Gender, Children and Social Protection
Ministry of Health/Ghana Health Service.
The following Intervention options are proposed for their
guidance to address the issues affecting the elderly in the
country.

44. 1.Ministry for Gender, Children and Social
Protection
• Increase in the enrolment of elderly(70+) on the
National Health Insurance Scheme (NHIS)
• National Council on Ageing
• Established ageing desk
• Senior Citizens’ Day :1st July
• Older People Monitoring Groups (OPMG

45. Ministry of Health and Ghana Health Service
1. Develop health implementation plan of the Ageing policy (GHS)
and integrate ageing and health in the Community Health
Planning and Services programme.
2. Build health workforce capacity at all levels of the health system,
among all categories of professionals through: professional
development of existing staff, in service development for existing
staff, and pre service training
3. Create age-friendly health facilities, and triaging in favour of the
elderly in al l health facilities.

46. 4. Broaden the health insurance package and coverage to take
care of special needs of the elderly.
5. Establish mechanisms to make assisted devices for hearing and
visual impairment available to people in need.

47. Recommendations
Recommendations are made to improve the quality
of life of the aged in the Ghanaian society:
– National Budgetary provisions
– National old-age pension schemes
– Targeted health care
– Community and family care
– Scaling-up the availability of age-disaggregated data
– Learning from experiences of older populations
– Increase retirement age from the current 60 years to 65
years

48. Limitations of policy implications in Ghana
• National Health Insurance benefits package not covering
a number of health conditions of the elderly such as male
cancers (only breast and cervical cancers are covered),
biopsy and histology.
• Despite the weak economic base of Ghana, when it
comes to elderly policy it should be above economic
capabilities to developing strong institutional and
policy framework.
• One of the major concerns of older persons in
Ghana is the absence of a comprehensive, coherent
and well-articulated policy document on ageing.

49. • Based on the evaluation of Ghana’s elderly care policy
with best practices in the world especially the EU’s
CARMEN model, it is evident that Ghana’s current
model even though provides what it calls “dignity for
the elderly” is in need of substantial revision
• Implementation of the draft Ageing Policy of 2010, which
was approved by Cabinet with its Action Plan in
November, 2010, and launched in 2011 has been
adversely affected due to absence of a proposed Ageing
Council and legislative backup.
• Absence of an Ageing Council and legislative
backup has affected implementation of the Ageing
policy drafted in 2010.

50. • The elders are not involved in managing the policy, the
elders are not involved in reviewing the policy, the elders
are not aware of its content and what is due them, there is
weak institutional and resource support to implementing
the policy and there is no legally binding responsibility on
governments to implement the policy.
• There is weak regulation and inspection of implementation
of policy and a weak evaluation and monitoring process of
the policy

51. • Ghana’s national policy for the aged has a strong
and clear vision because it is adopted based on the
experiences of developed countries such as Japan
and the EU.
• The 1992 Constitution makes it categorically
clear in Article 37(6b) that the "State provides
social assistance to the aged...to enable them to
maintain a decent standard of living"
Policies as an advantage to Ghana

52. • Ghana’s elderly care policy is well crafted and has
integrated both domestic and national variables
towards effective management of elderly in society
• The country is gradually witnessing the
emergence of private professionalized social
care for the elderly, arguably as replacements for
the deterioration in intergenerational
reciprocities.

53. Existing public policies such as the (a) the Pensions
Program, (b) the National Health Insurance Scheme
(NHIS), and the (c) Livelihood Empowerment Against
Poverty (LEAP) designed to address the challenges of
income insecurity, health care needs, and other
constraints imposed by abject poverty among the
elderly have proven palpably inadequate.
Conclusion