1.4 Research question . ... Figure 3.4 Ghana Health Service healthcare services by level . .... empirical chapters form the basis for papers for journals. .... in particular, in ensuing years (McCracken and Phillips, 2017a; Kinsella and He, .... schemes with little coverage, lack of nursing and ancillary homes, and deteriorating.
AGEING, HEALTH AND HEALTH-SEEKING BEHAVIOUR IN GHANA
GYASI RAZAK MOHAMMED
PHD
LINGNAN UNIVERSITY
2018
AGEING, HEALTH AND HEALTH-SEEKING BEHAVIOUR IN GHANA
by GYASI Razak Mohammed
A thesis submitted in partial fulfilment of the requirements for the Degree of Doctor of Philosophy in Social Policy
Lingnan University
2018
ABSTRACT
Ageing, Health and Health-Seeking Behaviour in Ghana
by
GYASI Razak Mohammed
Doctor of Philosophy
Rapid ageing of populations globally following reductions in fertility and mortality rates has become one of the most significant demographic features in recent decades. As a low- and middle-income country, Ghana has one of the largest and fastest growing older populations in sub-Saharan Africa, where ageing often occurs ahead of socioeconomic development and provision of health and social care services. Older persons in these contexts often face greater health challenges and various life circumstances including role loss, retirement, irregular incomes and widowhood, which can increase their demand for both formal and informal support. This thesis addresses the effects of the socio-political structure, informal social support and micro-level factors on health and health-seeking behaviour among communitydwelling older persons in Ghana. The theoretical perspectives draw on political economy of ageing, social convoy theory and Andersen’s behavioural model. Using multi-stage stratified cluster cross-sectional survey data of older cohorts (N = 1,200) aged 50 years and older, multivariate generalised Poisson and logit regression models estimated the associations among variables and interaction terms. Although Ghana’s national health insurance scheme (NHIS) enrollment was significantly associated with increased log count of healthcare use (β = 0.237), the relationship was largely a function of health status. Moreover, the NHIS was related with improved time from onset of illness to healthcare use (β = 1.347). However, even with NHIS enrollment, the intermediate (OR = 1.468) and richer groups (OR = 2.149) had higher odds of seeking healthcare compared with the poor. In addition, features of meaningful informal social support including contacts with family and friends, social participation and remittances significantly improved psychological wellbeing and health services utilisation. Somewhat counter-intuitively, spousal cohabitation was associated with decreased health services use (OR = 0.999). Whilst self-rated health revealed a strong positive association with functional status of older persons (fair SRH: β = 1.346; poor SRH: β = 2.422), the relationship differed by gender and also was moderated by marital status for women but not men. The employed and urban residents somewhat surprisingly had lower odds of formal healthcare use. The findings support the hypotheses that interactive impacts of aspects of structural and functional social support and removal of catastrophic healthcare costs are particularly important in older persons’ psychological health and health service utilisation. Nevertheless, Ghana’s NHIS currently apparently lacks the capacity to improve equitable attendance at health facility between poor and non-poor. In contributing to the public health and social policy discourse, this study proposes that, whilst policies to ensure improved health status of older people are recommended, multidimensional
social support and NHIS policy should be properly resourced and strengthened so they may act as critical tools for improving health and health services utilisation of this marginalised and vulnerable older people in Ghana. Moreover, policies targeting and addressing economic empowerment including universal social pensions and welfare payments should be initiated and maintained to complement the NHIS for older people. The achievement of age-relevant policies and Universal Health Coverage (UCH) as advocated by WHO could be enhanced by adopting some of these suggestions.
DECLARATION
I declare that this is an original work based primarily on my own research, and I warrant that all citations of previous research, published or unpublished, have been duly acknowledged.
-------------------------------------------(GYASI Razak Mohammed)
Date:
TABLE OF CONTENTS TABLE OF CONTENTS ........................................................................................... i LIST OF FIGURES ................................................................................................... ii LIST OF ABBREVIATIONS................................................................................... iii ACKNOWLEDGEMENTS ....................................................................................... v CHAPTER ONE ........................................................................................................ 1 INTRODUCTION TO THE STUDY ........................................................................ 1 1.1 Introduction.......................................................................................................... 1 1.2 Ageing and health—global and regional trends .................................................. 2 1.3 The problem and rationale of the study ............................................................... 8 1.4 Research question .............................................................................................. 13 1.5 Research objectives ........................................................................................... 14 1.6 Summary ............................................................................................................ 14 1.7 Organisation of the thesis .................................................................................. 16
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LIST OF FIGURES Figure 1.1 The organisation of the thesis................................................................. 17 Figure 2.1 Model of healthcare system in Ghana based Kleinman’s internal structure of health system ........................................................................................ 19 Figure 2.2 Conceptual framework – based on the Social convoy model ................ 20 Figure 2.3 Conceptual framework – based on the social convoy model ................. 20 Figure 2.4 Conceptual framework: based on Andersen’s behavioural model ......... 21 Figure 2.5 Theoretical Framework for the Study .................................................... 22 Figure 3.1 The political map of Ghana in the context of Africa.............................. 23 Figure 3.2 The rate of growth of older population sector aged 60+ in Ghana. ....... 24 Figure 3.3 The structure of Ghana Health Service .................................................. 24 Figure 3.4 Ghana Health Service healthcare services by level ................................ 25 Figure 3.5 Ghana Health Service facilities .............................................................. 26 Figure 3.6 Sources of revenue to the National Health Insurance Fund (NHIF) ...... 27 Figure 4.1 Summary of the methodological framework .......................................... 28
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LIST OF ABBREVIATIONS
ADL AHPWHB
Activities of Daily Living Ageing, Health, Psychological Wellbeing and Health-seeking Behaviour Study
AU CAM CBHISs
African Union Complementary and Alternative Medicine Community-Based Health Insurance Schemes
CHPS
Community-based Health Planning and Services
CSPS
Center for Social Policy Studies
DANIDA
Danish International Development Agency
DDHSs
District Director of Health Services
DHD
District Health Directorate
DHISs
District Heath Insurance Schemes
FD
Functional Decline
GDP
Gross Domestic Product
GHS
Ghana Health Service
GPAQ
General Physical Activity Questionnaire
GSS
Ghana Statistical Service
HCU
Healthcare Use
HIV/AIDS
Human immunodeficiency Virus/Acquired Immune Deficiency Syndrome
HSE
Health Survey for England
IADL
Instrumental Activities of Daily Living
KATH
Komfo Anokye Teaching Hospital
KNUST
Kwame Nkrumah University of Science and Technology
LAMICs
Low- and middle-income countries
LEAP
Livelihood Empowerment Against Poverty
MeTA
Medicines Transparency Alliance
MIPAA
Madrid International Plan of Action on Ageing
MOH NCCIH
Ministry of Health National Center for Complementary and Integrative Health
NCD
Non-communicable Disease iii
NHIA
National Health Insurance Authority
NHIS
National Health Insurance Scheme
NHIF
National Health Insurance Fund
NIAAA OECD
National Institute on Alcohol Abuse and Alcoholism Organisation for Economic Co-operation and Development
PWB
Psychological Wellbeing
SAGE
Study on Global Ageing and Adult Health
SDGs
Sustainable Development Goals
SRH
Self-rated Health
SSA
sub-Saharan Africa
SSNIT
Social Security and National Insurance Trust
TBA
Traditional Birth Attendant
TRM
Traditional Medicines
UHC
Universal Health Coverage
UN
United Nations
UNAIDS
Joint United Nations Programme on HIV and AIDS
UNDESA
United Nations DESA Population Division
UNICEF
United Nations International Children's Fund
WHO
Word Health Organization
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ACKNOWLEDGEMENTS I owe grateful acknowledgement in praise to God, who has showed many wonderful blessings on me; my daily living, family, friendship, sponsorships and the opportunity to complete this study. The scholarship reflected in this thesis would not exist was it not for the combined synergy, effort, help and support I received from a number of people and institutions. I take this opportunity to express my gratitude for their unmeasurable contributions. I express my sincere gratitude to my supervisors, Prof David R Phillips and Prof Roman David for their unparalleled supervisory métier. They allowed me to try, see, touch, learn and to think independently throughout my doctoral journey. Prof Phillips, ‘the Handsome Guy’, has been a mentor, father and a friend. His great passion and immense knowledge of ageing and health not only helped me develop deep interest in this field but also stimulated clear thinking for new ideas. He always says to me, “You are a powerhouse of producing publications, one of the most productive PhD students I have ever supervised in my career of 40 years and most importantly, the most pleasant and thoughtful student... You’re a credit to Ghana”. These comments have been my inspiration and will forever be my sense of purpose and life philosophies. Prof, many thanks for believing in me. Prof David’s generous support has been a rock behind this research endeavour. He has taught me with passion, firm and fair, and always refers me to as the most impressive and productive PhD student. Remarkably, Prof David taught me not only in theory, but also in practice. His valuable advice on my study will contribute to my success in the future. I say, thank you, Prof David, we have really produced this knowledge together. Above all, both my supervisors have helped and v
encouraged me to publish high impact papers as I have gone along. Some of the empirical chapters form the basis for papers for journals. For these, I undertook the analysis based on the data set from my Ghana Ageing, Health, Psychological Wellbeing and Health-seeking Behaviour Study (AHPWHB) explained in Chapter 4, and I did the write-up as lead author, with suggestions and inputs from my supervisors and other experts from Ghana. With further analysis, more outputs on a variety of topics are in submission and will undoubtedly be forthcoming. I gratefully acknowledge Lingnan University and its vibrant department, the Department of Sociology and Social Policy, for my three-year scholarship and Postgraduate Field Travel Grants. Prof Joshua Ka Ho Mok (the Vice President of Lingnan University), Prof Peter Baehr, Prof Paul O’Connor, Prof Stefan Kuehner and Prof Esra Burak Ho of Lingnan University; Prof Daniel Buor, Dr Charlotte Monica Mensah, Dr Kabila Abass, Mrs Lawrencia Pokuah Siaw, Dr Divine Odame Appiah and Dr Gabriel Eshun of Kwame Nkrumah University of Science and Technology also deserve special mention for their continuous encouragement and support. I deeply appreciate your sharing of rich academic and lifetime experiences. My sincere thanks also go to Ms Grace Wong and Ms Annabella Wong for their administrative support and guidance throughout my doctoral research. I am also indebted to all my colleagues and friends in Lingnan and Ghana especially Mr Burnett T. Accam for being there for me always. I owe heartfelt gratefulness to my family for their continuous support and love. I am especially indebted to my brother, Prof Anokye M Adam and uncles, Mr. Rockson Agyei, Mr. Abdallah Boansi Kyeremateng, Chief Inspector Saeed Boakye Yiadom and Nana Amo Mensah who have been part of my thoughts and actions with
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their boundless support and encouragement from the start to the completion of this study. Finally, I dedicate this piece of work to the memory of my late mother, Madam Ama Boansiwaa Abiba who encouraged me, invested in me and wished to see my PhD evolved and how my doctoral training contributed to societal development. May your tender soul continue to rest in peace.
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CHAPTER ONE INTRODUCTION TO THE STUDY
1.1 Introduction Population ageing1 is now occurring in nearly every region and country globally although with considerable disparities the world over. The trend to demographic ageing, whilst a huge achievement has become somewhat of a global concern in the policymaking arena, healthcare sector and the scientific community, as it impinges on numerous societal developmental issues. The United Nations (UN) (2013) explains that population ageing is the most distinctive demographic process and important challenge of this century. This interest has been building over decades and 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. Many other international recognitions followed. The European Union entitled 2012 as the Year of Active Ageing and Solidarity between Generations. In the same year, the WHO dedicated its annual World Health Day to ageing. Prior to that, the 1994 International Conference on Population and Development in Cairo brought to attention the huge growth in population ageing and its potential concomitant consequences. In April 2002, world leaders met in Madrid for the Second UN World Assembly on Ageing and adopted the Madrid International Plan of Action on Ageing (MIPAA) (WHO, 2013; UN, 2007; 2002; 1994). These international events not only
1
Demographic ageing describes the process by which older people increasingly constitute a proportionally larger share of the total population (Maharaj, 2013; UN, 2013; Kinsella and Phillips, 2005).
1
consolidated the 2002 WHO’s Active Ageing Policy Framework but also amassed inclusive strategies to address ageing concerns and implications for global and regional development (Kowal et al., 2012; Kowal et al., 2010; Hirve et al., 2013). Most importantly, 7 April 2018 marked the WHO’s 70th Anniversary dubbed, Universal Health Coverage (UHC): Everyone, Everywhere. On this anniversary, the WHO stressed their achievements and relaunched the target for UHC of reaching a billion more people including older cohorts by 2023. The current study is therefore very timely as it explores and provides current evidence on health and healthcare for often vulnerable older people in a low- and middle-income country (LAMIC) context.
1.2 Ageing and health—global and regional trends Statistics show that about 200 million older adults—60 years and older—lived around the globe in 1950; which had increased to 600 million by 2000 and to 901 million people in 2015, representing 12.3% of the global population (WHO, 2015a; World Alzheimer Report 2015; UN, 2014) and soon to reach a billion. This represents a five-fold increase in the number of older people in the time WHO has existed. The older population is projected to reach 1.4 billion by 2030 and then double again (from 901 million in 2015) to just over 2 billion people (21.1% share of the global population) by 2050 (WHO, 2015a). It is further estimated that older persons will outnumber children for the first time in demographic history by 2047 (UN, 2014). This ageing trend has raised serious ‘moral panic’ and therefore warrants a critical attention especially as many aspects of the panic can be avoided by good policy planning and sensible service provision (Walker, 2009).
2
Whilst ageing processes are not new to the economically more developed regions, many countries of the “Global South” are experiencing ageing as a relatively newfound phenomenon as it becomes increasingly evident in these regions. Much research has expounded that the less developed countries (LDCs) that are least prepared to confront the challenges of rapidly ageing population are currently ageing at much faster pace than their industrialised counterparts historically did (UN, 2006; Debpuur et al., 2010). Indeed, the UN (2014) noted that over 66% of the world’s older people currently already reside in the low- and middle-income countries (LAMICs). More so, about 70% of the world’s older people will live in LAMICs by 2025 and then increase to 80% by 2050 (UN, 2014; Velkoff and Kowal, 2007; Xavier et al., 2010). These projections show that population ageing has become a reality of our times and it will continue to afflict humanity like never before. In Africa, people aged 60 and older accounted for 5.1% (41.2 million older people) of the population just at the turn of this century. This figure had increased from approximately 12 million in 1950 and had risen again to about 50.5 million people in 2007 (UN, 2007). According to World Report on Ageing and Health (WHO, 2015a) the population aged 60-plus in Africa reached 64.5 million in 2015 and is likely to hit 103 million by the year 2030. Projections further suggest that there will be 205 million older adults (approximately, 11.3% of the total African population) by 2050 (WHO, 2015a; UN, 2009; Kinsella and Phillips, 2005). The West African sub-region will probably accommodate the greater share of this older people, and Ghana and Nigeria will experience an unparalleled proportional growth.
3
It is, of course, widely acknowledged that the challenge is not about the mere increasing numbers, more that population ageing in Africa is occurring in the context of widespread absolute and relative poverty, instability and conflicts, changing family structures and support systems, a disease burden including the HIV/AIDS pandemic and regional Ebola outbreak in 2014-16, weak health systems and often unstable political institutions (MacCracken and Phillips, 2017b; Maharaj, 2013; Apt, 2013). The African continent is more likely to confront the challenges of ageing before it achieves economic development, unlike many Western counterparts. This demographic transition has been achieved as a combined result of improvements in food supply, water and sanitation, advances in public health, medical technologies and relative economic development as well as efforts that have propelled world economies to overcome many parasitic diseases and injuries (Debpuur et al., 2010; Kinsella and Phillips, 2005; He et al., 2005). A number of factors related to child spacing and reduced family size have combined to lead to more people living longer today (Hooyman et al., 2015). Although the Western world has in general attained sustained lower fertility over the last four decades, most LAMICs in recent years are still at or above the replacement level2 particularly in Africa (UN, 2007; Kinsella and Phillips, 2005; Omran, 1998). It is therefore anticipated that the proportion of older citizens will grow rapidly as fertility falls further in the developing world and sub-Saharan Africa in particular, in ensuing years (McCracken and Phillips, 2017a; Kinsella and He,
2
The total fertility rate at which women would have only enough children to replace themselves and their partner. At this rate, population growth through reproduction will be approximately zero, but will also be affected by male-female ratios and mortality rates (Rodolfo, 1984). It is normally presented as being around 2.1 children per woman (Smallwood and Chamberlain, 2005).
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2009; UN, 2006). The Madrid International Plan of Action on Ageing in 2002 encouraged countries to mount a holistic approach to help older persons to maintain their independence, productivity and retain vital resources for their families, communities and the entire country (Maharaj, 2013; Kinsella and He, 2009). These positive issues could be reflected in good health. Proactive efforts—policies and programmes—such as health promotion, universal and equal access to healthcare services, universal health financing and proper pension schemes are deemed critical to improve the health of older persons. Demographic ageing of populations almost inevitably has major far-reaching consequences, not only for older people themselves but also for the socio-economic conditions, healthcare systems and policy directions of most countries, and has particular significance for the African Region (WHO, 2014a; Minicuci et al., 2014; de Carvalho et al., 2015). Accumulated evidence suggests that there is also a marked gendered disparity in ageing and its impacts, particularly in the African Region. Studies have shown variously that the majority of older adults comprise women (Kinsella and Phillips, 2005; WHO, 2015a). This trend increases with age because women tend to live longer than men3, so older women outnumber their male counterparts in almost every country. In 2013, for example, there were 85 men per 100 women in the age group 60-plus and 61 men per 100 women in the age group 80 years or over worldwide (UN, 2014). This gendered differential in ageing has profound implications for individuals and the society regarding marital status, living arrangements and
3
Men generally have higher death rates than women at all ages due to complex biological, social, and behavioural factors. This feminisation of ageing is a global phenomenon but presents a distinctive face in African economies such as Lesotho where over 65% (81,187) of the older people constituted women in 2016 (Lesotho Bureau of Statistics, 2013).
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economic conditions as widespread widowhood and lack of formal and emotional support may exacerbate poverty and health conditions of older women (Hooyman et al., 2015; Kinsella and He, 2009). The debate over the benefits and challenges of population ageing particularly in the developing world has received considerable attention for several decades. The phenomenal current ageing trend is often credited as a global human public health success story (Administration on Ageing, 2013; Hooyman and Kiyak, 2011). Kinsella and Phillips (2005) noted enthusiastically that ageing is a cause for celebration since it reflects our achievements in dealing with the perils of infectious and parasitic illnesses, childhood disease and maternal mortality and in helping women take control over their own fertility. It has also been noted that malaria, tuberculosis and HIV/AIDS and many other maternal/infant illnesses that caused over 300 million illnesses and more than 5 million deaths each year over a few decades ago are now receding (McCracken and Phillips, 2017a; WHO, 2013). Nevertheless, population ageing could certainly lead to many ensuing challenges, particularly in LAMICs where most dramatic change is felt, and where policies are often weakest. Epidemiological transition4 also has strong associations with population ageing. Population ageing in LAMICs has specially implicated the healthcare services for the older citizens especially the oldest-old5 in these countries
4
Transition from the predominance of infectious and parasitic diseases to the growing importance of non-communicable diseases and chronic conditions (Kinsella and Phillips, 2005; McCracken and Phillips, 2017a). 5 Persons aged 80 years or over. This cohort of older population is growing faster than other older groups globally and in both regional and local scales (WHO, 2015).
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(McCracken and Phillips, 2017b; Tollman et al., 2008; United Nation, 2013; Ahmed et al., 2001). Indeed, many African countries, including Ghana, face double burden of high levels of both communicable and non-communicable diseases (NCDs) (McCracken and Phillips, 2017a; 2017b; UN, 2014). Studies report that older persons are more likely to experience malnourishment, multimorbidities (Banerjee, 2015; McCracken and Phillips, 2017a), mental and emotional disorders including dementias, depression and wide range of psychological problems (Aboderin, 2015; Maharaj, 2013). Current global mortality from age-specific diseases and disabilities—chronic NCDs and injuries—remains disproportionately and unacceptably high among many older persons. According to WHO (2014; 2010) over 38 million people die annually from NCDs, mainly cardiovascular diseases, cancers, chronic respiratory diseases, dementia and diabetes. Other estimates also suggest that about 20% of older persons suffer from mental disorders whilst about 6.6% of all disability among over 60s is attributed to neurological and mental illnesses (World Alzheimer Report, 2015). Frailty, disability and complex chronic conditions that accompany old age not only subject older persons to physical and emotional suffering that require external support but also put increasing pressure on the health systems, particularly in sub-Saharan Africa and other poorer areas. In addition, over 26 million deaths from these NCDs occur among older persons, of which 85% are in developing countries (WHO, 2014b). Population ageing places rising demands on healthcare systems that can efficiently address multimorbidities among older persons. Unfortunately, the healthcare systems of many LAMICs still heavily focus on maternal, childhood and infectious diseases as well as reproductive health services with little attention paid to
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older people’s care needs. Until relatively recently, ageing and healthcare issues in the sub-Saharan Africa have received limited policy attention. To effectively and efficiently respond to the growing health needs of ever increasing older populations, it is critical to have in-depth exploration specific healthcare needs and the trajectories of health-seeking behaviour as well as public policy responses to the health situation of older populations. In that way, we could recount the saying that, “ageing is not a disease; ageing is a developmental process” as echoed by the WHO (2014c).
1.3 The problem and rationale of the study Like other parts of the world, population ageing has led to increases in the prevalence and the burden of wide range of disabilities and chronic diseases in Ghana (WHO, 2014b; Tawiah, 2011)6. Today, the major causes of death and disease burden in Ghana have shifted from previously mainly communicable and parasitic diseases to a triple burden of communicable episodes, chronic non-communicable diseases (NCDs) and injuries and the associated disabilities and trauma, primarily due to ageing, lifestyle and occupational changes (Bosu, 2013; Aikins et al., 2012; Ministry of Health, 2011a; McCracken and Phillips, 2017a). Indeed, the burden of NCDs has become an “emerging epidemic” which is evident in both urban and rural Ghana. Studies estimate that chronic NCDs are responsible for an estimated 34% of Ghana’s total deaths, killing 78,000 persons annually (Bosu, 2013; WHO, 2011a). As regards older people, hypertension, cardiovascular diseases (stroke), diabetes and dementia are the leading causes of NCDs admissions and an estimated 15% of the total deaths in Ghana. For example, a survey found an increased prevalence of
6
The background to Ghana is given in Chapter 3.
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hypertension from about 25%-28% in 1976-1998 to about 37%-45% in 2002-2006 in Ashanti Region (Bosu, 2010). Cases in the poorest rural communities are even striking. Approximately, 20% of adults have high blood pressure in the KassenaNankana District in the Upper East Region (Kunutsor and Powles, 2009). Still, the prevalence of diabetes in Kumasi ranges between 4% and 9% and hyperlipidaemia, between 17% and 23% (Owiredu et al., 2008; Hill et al., 2007). Ghanaian women suffer more from these chronic illnesses than men (Biritwum et al., 2013; Tawiah, 2011; Debpuur et al., 2010) partly due their longer live expectancy at birth. These multimorbidities have had negative cumulative effects on the health sector, productive capacity and budgetary allocations vis-à-vis the escalating costs of health services for older persons in Ghana, often driving them into insecurity and destitution. Again, the socio-cultural support roles of older persons is increasingly becoming dented (van der Geest, 2016). Older people can no longer perform the enviable traditional functions of nursing the sick and taking care of children, due to poor health. Conversely, the cultural and extended family support system that provided intergenerational social support and informal care7 for many older persons in the African region have been changing, as an impact of migration, urbanisation and Westernisation (Pillay and Maharaj, 2013). Poor health systems, low pension schemes with little coverage, lack of nursing and ancillary homes, and deteriorating traditional extended family systems have contributed to the declining socioeconomic and poor health status of the older persons in Ghana (Apt, 2002; Xavier Go´ mez-Olive et al., 2010).
7
The care usually offered by close family members, neighbours and friends to the older persons. This care is important in countries where pension programmes are not wellestablished and popularised.
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The far reaching implications and the nagging effects of chronic NCDs and many other health challenges among older persons, are increasingly recognised. Unfortunately, Ghana’s health system is ill-equipped to meet the brunt of increasing NCDs and the associated injuries and disabilities that older persons progressively present with (Apt, 2013). An evidence-based health system to address the disease burden of older persons is almost not available (WHO, 2012a). Ghana’s health system today has proven largely inept to meet the rapid demographic changes and basic healthcare needs of its older people. The health system still focuses mainly on dealing with childhood and maternal health issues. In addition, unlike most developed and emerging economies, sub-Saharan African countries in general including Ghana do not have practical well-formulated policy frameworks and programmes to address older people’s healthcare and social support agendas. In a similar vein, the Millennium Development Goals (MDGs) that changed the face of public health in many developing countries failed woefully to prioritise older people healthcare development (Sustainable Development Goals (SDGs) since 2015 do slightly better). The plight of older persons is therefore not well met or even recognised in Ghana. Most of all, a majority (59%) of vulnerable older population reside in rural areas, they have low levels of formal education, and face greater challenges in healthcare access and stark inequalities exist (Biritwum et al., 2013). In many instances, indigent older adults, particularly the oldest-olds, are required to pay unaffordable user fees in order to access healthcare. The Ghana’s National Health Insurance Scheme (NHIS) was introduced to provide medical care support for older persons and to improve equitable access to healthcare but now seems unpopular
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(Tawiah, 2011; Bosu, 2013). The NHIS for example, does not cover medical examination and most medications for chronic NCDs (Gyasi, 2015; Kowal et al., 2010). In addition, older people often face a higher transport costs and sometimes walk long distances to get to a health facility. Even when at the facility, they spent most of the day sitting in a long queue waiting to be seen by a health professional (Buor, 2008, 2004; Apt, 2013). This deters many older persons from seeking the necessary and appropriate medical care either in a timely manner or altogether. Older people are often pushed into consumption of various unregulated medical modalities with sometimes unwanted consequences. Yet, improving the wellbeing of older persons is a major component to the overall societal development (Macia et al., 2015). A critical understanding of healthcare needs of older adults and how they manage to seek care remains a key requirement for older persons’ health protection and improvement towards healthy, productive and successful ageing in Ghana and most LAMICs. This knowledge may be crucial for policy and practice. Again, reliable data on issues such as the magnitude of healthcare needs and illness behaviour patterns among older adults is crucial not only to develop surveillance system. The data are also needed to inform the development of strategies to guard against the progression of rampant chronic and geriatric-diseases, injuries and associated disabilities, as well as to strengthen the healthcare system to meet older cohorts’ healthcare demands. Astonishingly, research on health and healthcare use among older adults, although critical to their well-being, still remains sparse in the populous Ashanti Region of Ghana. Most Ghanaian ageing studies largely report on shifts in demographic trends in the population, coping with old age (see Apt, 1993;
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Apt, 1996) and formal and family support systems (see Nantomah and Adoma, 2015; Aboderin, 2006; Apt, 1992). Other studies have investigated living arrangements of older people (Mba, 2013; 2010), older persons’ vulnerability (see Apt, 1993; Golaz and Rutaremwa, 2011), but seldom provide information on older persons’ health needs and treatment-seeking behaviour and the associated correlates. Despite the growth of research in Ghana on health-seeking behaviour, the literature is sparse on specific health challenges and the multilevel impacts on healthcare decisions and options of the older adults. Illness behaviours of diseaseand population-specific groups such as adolescents and nursing mothers are predominant in the empirical literature (see for example, Crommett, 2008; Akins et al., 1995; Buor, 2004; Russell, 2008). Even more so, like most other sub-Saharan African countries, there is a serious challenge of healthcare inequalities in Ghana (Buor, 2004). Unfortunately, the literature has failed to analyse the potential roles of micro-level factors, social network support, or the broader socio-political structure of the economy, in the inequalities of older people’s healthcare access and utilisation behaviour. These conditions individually or in concert with others may play out in healthcare practices and approaches among the older adults. This study breaks new ground by taking a critical look at the extent to which these variables impact on health and healthcare-seeking behaviour of older people. Up to this point, consideration has focused on the extent to which public policies are implemented to reflect the health needs and health-seeking patterns of older people and the conclusion is that they have been largely neglected. Moreover, the political economy aspect of ageing and old age have received very limited attention in sub-Saharan Africa and Ghana in particular. Recognising these
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shortcomings and to build on existing knowledge, this study attempts to fill the research gap in political economy by investigating the effect of health insurance coverage on health-seeking behaviour of Ghanaian older persons from a range of socio-economic backgrounds.
1.4 Research question Based on the forgoing discussion, the overarching research question addressed in this study is: How do wider societal/political features, interpersonal/social relations and micro-level dynamics influence older persons’ health and health-seeking behaviour? The study, therefore, explores the specific nature and the extent of healthseeking behaviour in later life in Ghana. The study aims to provide understanding into how healthcare needs and illness perceptions and experiences, predisposing as well as enabling characteristics, influence patterns of health-seeking behaviour among older persons. As noted, these issues are timely, given the limited research efforts and the projected rise in health challenges of the growing older population in Ghana in the not too distant future (Biritwum et al., 2013). Keen interest is also taken to examining the magnitude of healthcare access and behaviour inequalities among older people in relation to the range of social relations and support. Public policy should play a critical role in providing health and healthcare opportunities for older persons. The socio-political and political economic systems have a potentially even bigger role to play in ensuring equity in access to health services for older persons. In the Ghanaian system, like many others, social (public) policy instruments should be charged to minimise as far as possible, catastrophic healthcare costs especially through developing universal health protection policy for older people. This study
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therefore explores the extent to which Ghana’s sociopolitical structure impacts the health-seeking behaviour and access equity for older people.
1.5 Research objectives The central object of this study is to understand the extent to which wider societal/political features, interpersonal/social relations and micro-level dynamics influence older persons’ health-seeking behaviour. In order to answer this broad research question and to inform policy directions to redress the older persons’ health challenges, this study focuses on the following specific empirical objectives: 1. To examine the effect of Ghana’s National Health Insurance Scheme enrollment on access to healthcare and healthcare utilisation among older persons in Ghana 2. To analyse the dimensions and the associations of aspects of social support with psychological wellbeing in older persons in Ghana 3. To investigate the role of social support networks in health and health-seeking behaviour among older persons in Ghana. 4. To examine the relationships between subjective health and functional decline among older persons in Ghana. 5. To examine the contribution of demographic and socioeconomic variables to the health and health-seeking behaviour of older persons in Ghana.
1.6 Summary Today, the world is experiencing spectacular demographic and epidemiological changes the speed of which is largely unprecedented. Populations are growing older
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in almost every region and in every country across the globe, with numerous concomitant health and social care implications. The linkages between ageing and health have enjoyed considerable debate in professional circles, policymaking and implementation and in the academic literature for many decades. The subject becomes more interesting in event where the demographic ageing is new and profound which can be seen at the global, regional and the local scales. We already see associated increases in health problems (chronic non-communicable diseases, dementias, injury, and long term disabilities) and many other socio-economic and environmental challenges, particularly in LAMICs (WHO, 2014b; de Carvalho et al., 2015). Whilst the struggle and concern for active and successful ageing agendas are evident in policy and research endeavours in the UK and the USA and in many richer nations, the situation in Ghana, like many other bub-Saharan African countries reflects the reality that the healthcare and related systems in many cases are not resourced or well positioned to safeguard older persons’ welfare, wellbeing and adaptation in later life. In the fast changing circumstances in many sub-Saharan African countries, much less has been achieved in terms of policy directions, reinforced health systems and affordable long-term care to offset the possible consequences of vulnerability and poorer health conditions of their ageing populations. These current and near-future developments warrant the emphasis of ageing and health policy considerations and extensive research capacity building in such nations. In effect, research focusing on ageing dynamics, healthcare needspecifics and the health-seeking decisions among the older populations in the subSaharan African context must be prioritised.
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1.7 Organisation of the thesis This study is organised in nine subsequent chapters (Figure 1.1). As noted, chapter 1 has presented the background and general overview of the study and global and regional views of ageing and health interface. The chapter described the problem and the rationale, research question and objectives and the significance of the study. The chapter ends with an outline of the thesis. Chapter 2 reviews relevant empirical studies, aimed at placing the current study in the context of the existing academic and professional literature. A major component of this chapter relates to the theoretical considerations (the political economy of ageing, social convoys and behavioural theories) needed to explain the empirical discoveries of ageing, health, and health-seeking dynamics. The development of the hypotheses that guide the study is also explained in this chapter. Chapter 3 presents a brief profile and the background characteristics of the study context. Specifically, it discusses the geographical, demographic, political, sociocultural and economic situation of Ghana. Attention is also given to demographic ageing, ageing policies as well as the Ghanaian health system’s structure including the evolution and situation of the NHIS. Chapter 4 provides a detailed research methodology and the approach to this study and the collection of the data for the research. The chapter describes research design, delineation and measurement of study variables, scaling and sampling techniques. How ethical issues were addressed, data collection instruments, procedure and data analytical tools and processes are explained. Chapters 5, 6, 7, 8 and 9 constitute the main empirical chapters of the study. Chapter 5 focuses on the effect of Ghana’s National Health Insurance Scheme
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enrollment on access to health services and healthcare utilisation among older persons. The chapter also deals with the equity dimensions of access to healthcare.
Research Aims
Chapters
Thesis Structure
Chapter 1: Introduction Chapter 2: Literature Review
Empirical and theoretical account of ageing/health
Chapter 3: Study Context
Geography; SES; health systems profile
Chapter 4: Methods
Chapter 5: NHIS and HSB
Macro, interpersonal and micro-level impacts of health, wellbeing and healthcare in later life
Overview: ageing and health—global context
Fieldwork and data analysis Impact of NHIS on HCU and access equity
Chapter 6: Social Support and PWB
Social support networks and psychological wellbeing in later life
Chapters 7: Social Support and HSB
Multidimensional social support and HCU in old age
Chapters 8: SRH and functional decline (FD)
Chapters 9: SES, need and HSB
Chapter 10: Conclusions
Mediating role of marital status in SRH and FD associations in old age Socioeconomic inequalities and Health services use in later life Summary of findings; Research contributions; Recommendations: Further research agenda.
Figure 1.1 The organisation of the thesis Note: NHIS = National Health Insurance Scheme; SES = socioeconomic status; HCU = healthcare utilisation; HSB = health-seeking behaviour; FD = functional decline; PWB = psychological wellbeing.
Source: Author’s construct, 2017
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Chapter 6 discusses the prevalence and significance of social support networks to psychological wellbeing among older persons, whilst Chapter 7 addresses the role of social support networks in health-seeking behaviour among older persons. Chapter 8 examines the role of marital cohabitation in the relationship between subjective health and functional decline, whilst Chapter 9 discusses socioeconomic position and health services utilisation among older persons. Finally, Chapter 10 concludes with a brief overview of ageing, health/psychological wellbeing and health-seeking behaviour of older persons in relation to the theoretical and conceptual basis of the thesis. It considers the findings with respect to the constructs of political economy of ageing, social convoy model and Andersen’ behavioural model of health services utilisation. This chapter ends with summary conclusions and recommendations regarding what could be done at policy and practice levels to improve health and health services utilisation of older persons. It considers the limitations of the thesis and discusses an agenda for further research.
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Professional Sector Hospital-based Clinic-based Health centrebased
**
Popular sector Individual-based Family-based Social network-based Community-based
* **
** Folk sector Indigenous practices Alternative care Complementary care
Secondary pluralistic healthcare - Healthcare knowledge/use at the intersection of the three sectors. Primary pluralistic healthcare - Healthcare knowledge and use at the intersection ** of the two sectors. Figure 2.1 Model of healthcare system in Ghana based Kleinman’s internal structure of health system
*
Source: Author’s construct, 2017
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Family: parents, spouse, siblings, best friends Other wider relatives, coworkers, Acuentances, mail persons, bank tellers, people we meet irregularly
Figure 2.2 Conceptual framework – based on the Social convoy model
Source: Author’s construct, 2017
Figure 2.3 Conceptual framework – based on the social convoy model
Source: Author’s construct, 2017.
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Predisposing Factors Age Gender Marital status Ethnicity Education Religion
Health-seeking
Need factors
SRH IADL decline ADL decline Comorbidity Mental health Enabling factors NHIS enrolment Wealth/income Living arrangement Distance to facility Travel time/cost
Type Formal healthcare Informal healthcare Nature Hospitalisation care Outpatient services Purpose Preventive Curative Rehabilitative Custodial care Volume/quantity Frequency of visit Timing of visit Continuity measure
Figure 2.4 Conceptual framework: based on Andersen’s behavioural model
Source: Author’s construct, 2017.
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Enabling factors (macro-level) Facility Availability Distance to Facility Service cost Health insurance
Need factors
Health-seeking behaviour 1. Formal system 2. Informal system a) Self-care/popular system b) Traditional/folk system
1. Self-rated health 2. ADL/IADL 3. Chronic conditions 4. Psychological wellbeing Social support network
Couple-focused Family/friends contacts Social participation Remittances
Lifestyle behaviour Physical activity Smoking Alcohol use
Micro (individual)-level factors Age Education Gender Ethnicity
Household wealth/income Utility (value) Marital Status Residence
Figure 2.5 Theoretical Framework for the Study
Source: Author’s Construct, 2017.
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Figure 3.1 The political map of Ghana in the context of Africa
Source: www.mapsoftheworld.com.
Proportion of older adults to total population 14
12
12 10 6.9
%
8 6
4.5
4.1
5.2
4 2 0 1940
1960
1980
2000 YEARS
23
2020
2040
2060
Figure 3.2 The rate of growth of older population sector aged 60+ in Ghana.
Source: Author’s Construct, 2017.
Ghana Health Service Council Office of the Director General and Deputy Director General Eight National Divisional Directors
National level
Supported by Regional Health Management Teams Regions are headed by 10 Regional Directors of Health Services Regional Health Committees
Regional level
All 170 districts are headed by District Directors of Health Services Supported by the District Health Management Teams District Health Committees Sub-District Health Management Teams
District level
Sub-district level The 3 administrative levels of GHS
Community level Figure 3.3 The structure of Ghana Health Service
Source: Author’s construct (2017) based on the GHS, http://www.ghanahealthservice.org.
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Curative services are delivered at the regional hospitals and public health services by the District Health Management Team (DHMT) as well as the Public Health division of the regional hospital. The Regional Health Administration or Directorate (RHA) provides supervision and management support to the districts and sub-districts within each region.
Curative services are provided by district hospitals many of which are mission or faith based. Public health services are provided by the DHMT and the Public Health unit of the district hospitals. The District Health Administration (DHA) provides supervision and management support to their sub-districts.
Supported by Regional Health Management Teams Regions are headed by 10 Regional Directors of Health Services Regional Health Committees
Figure 3.4 Ghana Health Service healthcare services by level
Source: Author’s construct (2017) based on the GHS, http://www.ghanahealthservice.org
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Health Centre (rural) Medical Assistant and staffed with programme heads in the areas of midwifery, laboratory services, public health, environmental, and nutrition. Each health center serves a population of approximately 20,000. They provide basic curative and preventive medicine for adults and children as well as reproductive health services. They provide minor surgical services such as incision and drainage. They augment their service coverage with outreach services and refer severe and complicated conditions to appropriate levels
District Hospitals These are the facilities for clinical care at the district level. District hospitals serve an average population of 100,000–200,000 people in a clearly defined geographical area. The number of beds in a district hospital is usually between 50 and 60. It is the first referral hospital and forms and integral part of the district health system.
Polyclinic (urban) Polyclinics are usually larger, offer a more comprehensive array of services, are manned by physicians, and can offer complicated surgical services.
Figure 3.5 Ghana Health Service facilities
Source: Author’s construct, 2017
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Regional Hospitals
Revenue sources to NHIF
Taxes
72%
SSNIT contributions
20%
Investment income
4%
Premiums
3%
other sources
1%
0%
10%
20%
30%
40%
50%
Figure 3.6 Sources of revenue to the National Health Insurance Fund (NHIF)
Source: Author’s construct, 2017.
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60%
70%
80%
Study design
Pragmatism (Positivist philosophies)
Cross-sectional Quantitative approach DV: Health and health-seeking behaviour IV1: Socioeconomic and Demographic variables
Measures IV2: Health status/need variable IV3: Accessibility and health system variables IV4: Social support network
Sampling design
Selection of study districts and communities Sample selection Domain identification for questionnaire
Instrumentation Development of questionnaire items and scales Expert review and pre-testing of draft questionnaire
Data collection
Community, household and individual contacts Data verification and final coding
Data management Data entry and cleaning Management of missing data
Analytical approach
Data analyses and generation of study results
Figure 4.1 Summary of the methodological framework
DV = Dependent Variable; IV1…4 = Independent Variables Source: Author’s construct, 2016.
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Region
Middle Zone
North Zone
ND1
R
C C C
ND2
R
U
C
C C C
U
C
South Zone
MD1
U
SD1
MD2
U
C C C C
R
C C C
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R
U
C
C C C
SD2
R
U
C
C C
U
C
C
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p ˂ 0.001 for allopathic and traditional healthcare Self-care
Traditional healthcare
Allopathic 0%
10%
20%
30%
40%
50%
60%
70%
80%
90% 100%
per cent (%) Oldest olds
Old olds
Young olds
p ˂ 0.001 for allopathic and self-care Tertiary High school
Basic Never 0
10
20
30
40
50
60
70
Per cent (%) Self-care
Traditional healthcare
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Allopathic
80
90
Table 10.1 Summary of hypotheses, findings and key implications. Specific study objectives
Theoretical foundation
Hypotheses
Key findings
Key implications
Examine the effect of NHIS enrollment on access to and use of healthcare.
Political economy of ageing
Enrollment in the NHIS will (a) increase the frequency and also improve time from onset of illness to health services use (b) improve equitable access to healthcare between the non-poor and poor.
(a) NHIS increased the log count of healthcare use but the association was largely a function of health status.
(a) Expansion of NHIS premium exemption to include all over persons.
Analyse aspects of social support associated with psychological wellbeing of older adults.
Investigate the role of social support health services utilisation.
Convoy model of social relation
Those embedded in larger constellations of social support will (a) show improved PWB; (b) cause improved use of healthcare.
(b) NHIS increased the likelihood of using healthcare earlier. (c) With NHIS, the richer and socially integrated used healthcare more than the poor and socially isolated
(b) Additional social policies e.g. pensions, LEAP, etc to empower older persons economically may compliment the NHIS.
(a) Family contacts, living with spouse, having emotional bond, social participation and remittances improved PWB
(a) Opportunities for social integration should be provided by structural and community efforts.
(b) Household help had no relationship with PWB
(b) The novel implication of importance of remittances should be well-defined and strengthened:
(a) Family contacts, social participation, remittances, having caregiver increased health services use. (b) Pecuniary assistance decreased health services use.
(i) Education of young adults about health and healthcare benefits of remittances; (ii) Development of children’s support policy for remittances
Examine the associations between SRH and functional decline
(a) Selfperceived poor health status will lead to increases in
(a) SRH positively related with functional decline with slight gender differences. (b) Living with spouse moderated the
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(a) Interventions to improve health status through specialised care and marital cohabitation should
among older persons.
Andersen’s behavioural model
Assess the role of individuallevel factors in health services use among older persons.
health service use; (b) Urban dwelling and living with partner will increase health services use.
association among women only.
be provided by Ghana Health Service and the community.
(a) Suboptimal health status, health insurance education, growing older positively related with healthcare use.
(b) Socioeconomic status including geographical variations, marital status, and gendered perspectives should be considered in health planning and delivery strategies for older persons.
(b) Urban dwellers and the married were less likely to use healthcare.
(c) The study offers further policy implications for national and UN/WHO interest in UHC.
Author’s construct, 2018.
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