1963-2013 - 50 years of Research for Social Change

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Back | Project: Ageing, Development and Social Protection

Case Study by Di McIntyre

  • Project from: 2001 to 2003



This paper will consider health policy issues, with a particular focus on health sector reforms, in relation to older people in Africa. There has been almost no consideration of the impact of health sector reforms from the perspective of older people. Given the dearth of explicit literature on this issue, a two-fold strategy will be adopted in preparing this paper. Firstly, a contextual analysis of the characteristics and experience of older people in various African countries will be undertaken. This will allow the existing literature on health sector reform to be drawn on to explore the likely impact on older people. Secondly, some, albeit limited, primary analysis of relevant and accessible household survey databases will be undertaken.

The African Context

It is necessary before considering health sector reforms and their potential implications for older people in Africa to provide some contextual information. In particular, it is important to provide insights into the diversity of experience of older people, which needs to be borne in mind in the analysis of health policy and health sector reform.

A brief overview of the demographic, epidemiological and socio-economic profile of African countries will be provided, with particular reference to older people. Data will be summarised in appropriate tables and key issues highlighted. Particular emphasis will be placed on recent trends in the percentage of the population who can be described as elderly and the role of HIV/AIDS in this regard. In addition, the key health problems facing older people in Africa will be reviewed, depending on data availability. Finally, available data on the socio-economic status of the elderly will also been drawn on.

Three country case studies (one each in Southern, East and West Africa) will be undertaken to highlight the diversity of experience of the elderly in Africa. Living Standards Measurement Survey (LSMS) databases will be obtained for South Africa, Tanzania and Côte d'Ivoire, and the following data analysed in each dataset:

· Household composition (size, demographic composition etc.);
· Distribution of older persons across geographic areas (rural, peri-urban and 'formal' urban areas);
· Socio-economic status of households with older people as members, compared with other households;
· Reported illness in preceding two weeks, analysing the type of illness reported by older persons and the extent of reported illness between age groups; and
· Reported health service utilisation in preceding two weeks relative to reported illness, comparing between age groups.

Health Sector Reforms

A brief introduction to health sector reforms will be provided. The motivations underlying these reforms and the range of health sector reforms implemented in African countries will be reviewed briefly. Certain of the key reforms will be considered in greater detail in the following sections to explore the implications for older people.

- User fees
Given the economic challenges facing many African countries in the 1980s and 1990s, many governments introduced 'cost recovery' programs, particularly in terms of charging user fees for public health services. This was strongly advocated by the World Bank and was an integral part of Structural Adjustment Programs in many countries.

This section will draw on the extensive literature on user fees and highlight issues that are likely to be of relevance to older persons. This will be done by drawing on the contextual analysis provided earlier to infer which impacts are likely to affect older persons based on their socio-economic profile, geographic location etc. In addition, information on the extent to which the elderly are protected from the financial burden of fees, through explicit exemption from user fees in African countries' health policy documents, will be reviewed.

- Social Health Insurance
There is growing interest in introducing Social Health Insurance (SHI) in a number of African countries. While there are potential benefits of this financing mechanism given its potential for cross-subsidisation when based on social solidarity principles, it is unlikely to benefit older people to any great extent. This relates to the experience in low- and middle-income countries that SHI will initially cover those in formal employment and that it will take considerable time for universal coverage to be achieved. The introduction of SHI may in fact further marginalize older people in relation to equitable health services access.

- Creating an enabling environment for the private sector
A key health sector reform has been to change the public/private health sector mix. In particular, there have been initiatives to encourage governments to create an enabling environment for increased private sector financing and provision of health services. The implications of this, particularly in relation to the growth of private health insurance in some African countries, for older persons will be reviewed.

- Essential package policies
The flip side of the 'enabling environment for the private sector' coin is that of restricting government financing of health services to an essential package. The World Bank vociferously advocated such a policy, particularly within Africa (e.g. the through the 1993 "Better Health in Africa" report). Around the time of the release of the 1993 World Development Report, "Investing in Health" a flurry of 'burden of disease' studies were undertaken in a range of African countries, drawing on the DALY approach. The discrimination against older people in the DALY approach will be discussed briefly. In addition, the composition of the essential package proposed for African countries based on these 'burden of disease' studies will be critically evaluated in terms of the extent to which the services included in the package are likely to benefit the elderly. This will include reference to the types of primary care services that have internationally been shown to contribute to health improvements for older people.

- Other relevant policies
A number of other relevant health policies will be briefly reviewed, including:

· Private health insurance;
· Community-based pre-payment schemes;
· Decentralisation; and
· The World Bank/IMF's Poverty Reduction Strategy initiative.


Key findings of the above analyses will be summarised. In addition, recommendations on how to strengthen future research to monitor and evaluate the impact of health policies on older people will be presented.