Interventions for older people in sub-Saharan Africa

Lead Research Organisation: University of East Anglia
Department Name: International Development

Abstract

Between 2015 and 2050 the number of people aged 60 or more in sub-Saharan Africa is projected to roughly quadruple, reaching over 160 million. Hitherto, international development priorities have focussed on people at younger ages. There is now an urgent need to address this new challenge. It should not be assumed that policies for older people that proved effective in other world regions will be suited to sub-Saharan Africa. Current knowledge about "what works for older people" in the region is very limited.

We plan to address this knowledge gap by looking at the effects of three different policies for older people (screening for chronic health conditions, providing basic pensions and extending health insurance coverage) in two quite different countries: Ghana and South Africa. Using survey data that permit analysis over time, we plan to assess impacts of these policies on different aspects of older people's health and well-being. We will pay particular attention to high blood pressure (hypertension) and depression, as these conditions are closely linked to older people's general health and quality of life. Rather than collect our own information, we will make use of a number of existing surveys.

Building on insights we generated in a previous study, we will:

1) Examine and seek to explain changing patterns of hypertension among older people in Ghana and South Africa. Hypertension is the leading cause of death and serious illness among this group: understanding these patterns will support the development of more appropriate policy responses. We will look at who has hypertension, who is aware they have the condition and who is effectively managing it.

2) Assess the impact of screening for hypertension in South Africa on older people's awareness, treatment and control of the condition.

3) Assess the impact of Ghana's expanding national health insurance scheme on older people's health and wellbeing, including hypertension and depression.

4) Assess the impact of South Africa's old age grant on the health and wellbeing of older people, with a particular focus on depression and risk of death.

Our overall aims are to generate valuable research insights and to ensure these are effectively communicated to appropriate policy-makers. As such, a large part of the project will involve engaging with key global, regional and national policy-makers, including workshops, briefing papers and interaction through social media.

Planned Impact

We plan to develop the non-academic impact we generated in our first SDAI study. This study's explicit focus on policy interventions will enhance its potential impact. Lloyd-Sherlock (LS) has overall responsibility for impact. The budget includes specific impact time allocations for different team members. We will focus on impact generation in Ghana and South Africa, through "national impact-leaders" (Twine and Amoakoh-Coleman) with support from LS and other team members.

During inception, LS will work with the national impact leaders to develop national impact plans. These will build on stakeholder engagement in the first project. We will hold national stakeholder consultations during inception, and dissemination workshops in the final 6 months. These will enable continual stakeholder engagement and dialogue through the project.

Ghana is the only sub-Saharan African country in a translational research initiative with WHO and Age UK. Our previous study fed into this initiative and we will develop this role. Amoakoh-Coleman is based at the University of Ghana's School of Public Health, which has close and extensive ties with government policy makers, including the national health insurance agency.

In South Africa we will build on our previous engagement with government departments, NGOs and the national media. We will use the University of Witwatersrand's strong stakeholder networks. There are particular opportunities to influence the Ministry of Health to develop NCD screening programmes, contingent on our findings.

During inception we will create a database of policy-makers and stakeholders in the region. We will email a questionnaire and engage with members of the database on a regular basis. We will establish a stakeholder advisory group with whom we will engage a more intensively basis. We will hold stakeholder workshops in the final 6 months at: (i) at the London offices of HAI; (ii) Nairobi (African Population and Health Research Center); (iii) Geneva (WHO, ILO and UNRISD).

We will build on relationships with global stakeholders, including:

WHO: Since his secondment in 2011-12, LS still works closely with WHO. The directors of the WHO SAGE survey and Department of Ageing and Life Course were involved in our previous project and co-authored outputs. LS is contracted by WHO to support a new global strategy on older people's health. WHO have expressed a strong interest in collaborating with this project (see letter of support).

HAI was a key partner in our previous project, including a joint policy brief. HAI have expressed interest in collaborating with this project (see letter of support). Separately, LS is contracted by HAI to act as a senior academic adviser for a project assessing links between social protection and access to health services for older people in Ethiopia, Tanzania, Zimbabwe and Mozambique. There will be opportunities for synergies between these 2 projects, in terms of analysis, dissemination and regional impact.

To influence policy across sub-Saharan Africa, we have contracted Dr Aboderin from the African Population and Health Research Center. She is the leading global authority on older people in the region, with access to unparalleled networks. She will be a regional impact broker, also supporting a regional workshop and the production of a regional policy brief.

We will develop and extend our existing project website. We will include a new interactive facility for user comments.

We will publish a policy brief for each area of analysis. As in the first project, we will publish these jointly with stakeholders enhance their reach. We will translate the briefs into French and Portuguese (LS speaks both) to reach non-English-speaking stakeholders.

Publications

10 25 50
 
Description We have found:

That older people in rural South Africa who receive pensions spend a large part of pension income on unhealthy types of consumption (eg. tobacco and alcohol), and have very low rates of health awareness. This runs counter to a widely held view among policy-makers and NGOs that simply giving older people in sub-Saharan Africa will enhance their health. It demonstrates a need for pensions to be complemented with other health interventions.

Through a pilot intervention, we demonstrated the feasibility of combining pension delivery with basic health interventions (screening for hypertension and providing pensioners with regular supplies of low sodium salt) in rural South Africa.

We have shown that coverage of older people in Ghana's National Health Insurance has risen over time, but that use of health services has fallen and that there are no associations between being insured and having better health in later life.

We have demonstrated the prevalence of depression among older people in Ghana and, through a small intervention, the value of community-based screening and talking therapies for this condition.

Further findings are pending confirmatory analysis.


Analysis is ongoing and at a preliminary stage. However, we have found high and increasing rates of obesity among older people in Ghana and only limited evidence that extending health insurance in Ghana has led to increased use of health services among older people. We have validated the SAGE depression tool with a small qualitative study in Ghana.
Exploitation Route Some findings already used by Alzheimer's Disease International.

We have shared our findings about pensions and consumption with international stakeholders (eg ILO and HelpAge International). They were not especially receptive, since our findings challenge elements of their established advocacy agendas. We will continue to engage.

We have shared the findings of the pension and salt intervention with stakeholders locally, nationally and internationally. We are looking to scale-up with a full trial. Funding application to Links Community pending.

We shared our findings on depression with HelpAge Ghana, who, as a result, are including interventions as part of their regular old age club activities.

We have started to share our findings on Ghana insurance with national stakeholders (health and insurance agencies, NGOs, etc). In part, we did this through key informant interviews, which will be included in the final version of the paper we are drafting. Our results have surprised them and they are looking to validate them with other data sources. They may go on to investigate barriers to serviec use by older people.

We are holding a regional meeting in Kenya in June, where the findings will be shared with stakeholders from different countries. Social pensions and social health insurance are major areas of policy interest in the region, and we envisage that our studies from 2 different countries will influence policy debates elsewhere.
Sectors Financial Services, and Management Consultancy,Healthcare,Government, Democracy and Justice

 
Description Preliminary engagement with a range of local and global stakeholders. For example, we collaborated closely with a local NGO, HelpAge Ghana, in a study on depression among older people in Accra, Ghana. They have now agreed to make this a priority area of action for their organisation.
First Year Of Impact 2018
Sector Healthcare
Impact Types Societal

 
Description Peru develops and funds evaluation of intervention to link pensions and hypertension
Geographic Reach National 
Policy Influence Type Influenced training of practitioners or researchers
 
Description South Africa MRC develops larger trail for hypertension screening at pension paypoints
Geographic Reach National 
Policy Influence Type Participation in a national consultation
 
Description A STUDY TO LOWER BLOOD PRESSURE IN ELDERY PEOPLE QUEUING TO COLLECT OLDER PERSONS GRANTS 
Organisation Medical Research Council of South Africa (MRC)
Country South Africa 
Sector Public 
PI Contribution Building on our feasibility study of treating hypertension at pension paypoints, MRC South Africa has commissioned members of the original research team to run a scoping study for rolling out a similar intervention on a larger scale. The scoping study will run during 2020 and may lead to a wider initiative.
Collaborator Contribution Funding and policy engagement with the national ministry of health in South Africa.
Impact Multi-disciplinary: epidemiology, gerontology, economics
Start Year 2020
 
Description Health insurance and older people in Ghana 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact A half-day policy-maker workshop in Accra in February 2018. Participants included representatives of the National Health Insurance Scheme, the NGO HelpAge International, and the Ministry of Health. We shared data and analysis on the effects of health insurance that they had not previously been able to access. This indicated that the effects of health insurance on measured health outcomes are not as direct as they had previously thought, and that rates of service use had declined. They found this very surprising and said they would share with their colleagues.
Year(s) Of Engagement Activity 2018
 
Description Health interventions for older people in Ghana and South Africa: findings and regional implications 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Social protection and health interventions for older people in Kenya and sub-Saharan Africa:
Experiences, impacts and directions for the future



A research dissemination and discussion forum



13 June 2019
PanAfric Hotel, Nairobi


convened by:

National Social Protection Secretariat (NSPS)
African Population and Health Research Center (APHRC)
School of International Development, University of East Anglia, UK
Centre for Research on Ageing (CRA), University of Southampton, UK
Year(s) Of Engagement Activity 2019
 
Description Interventions linking pensions and salt in South Africa 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact We held a dissemination workshop with a mixed audience of public, policy-makers and practitioners in our field site in South Africa. As well as presenting findings, we held discussions with the local director of the Social Security Agency and the district health office about developing and scaling up the pilot intervention. This has led to the development of a draft funding proposal, which we have shared with the Links Foundation, and who have encouraged us to make a full application later in 2019.
Year(s) Of Engagement Activity 2018
URL https://www.community-links.org
 
Description SAGE, pensions and health insurance in Africa 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact I was attended to participate in an expert the WHO annual meeting of the WHO Clinical Consortium on Healthy Ageing, 11-12 December 2018. I presented on a different project, but was invited by the Director of the WHO SAGE survey for an informal meeting with him to discuss unpublished findings from this project. I was invited to continue the analysis with the forthcoming 3rd wave of SAGE and will be given direct access to it.
Year(s) Of Engagement Activity 2018
 
Description Social protection and health: evidence from sub-Saharan Africa 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Presentation to Social Protection Department of International Labour Organisation in Geneva. Chaired by the Director of the Department. 25 ILO social protection experts attended. Presentation of findings, some of which challenge general claims made about social protection and health by ILO. These were politely received, but my impression was that they would have been much more receptive to findings that confirm, rather than challenge, their existing views.
Year(s) Of Engagement Activity 2018