Increasing acceptability, accessibility and affordability of health care among the elderly in Africa using models developed, implemented and evaluated in the Nigerian setting

1. Increasing acceptability, accessibility and
affordability of health care among the elderly
in Africa
Amara Frances Chizoba. MPH, BNSC, RPHN,AAHIVS
Director, Mission to Elderlies Project, RHF Nigeria
www.missiontoelderlies.org
missiontoelderlies@gmail.com

2. • Introduction

3. Geriatric burden in Africa
• The face of Africa is changing.
• According to the global aging report [1,2], by
2050, the number of people over 60 living in
Africa will increase from just under 50 million
to just under 200 million.
• In Nigeria, the elderly is estimated to
constitute 10% of population in 2016 as
against the 8% population in NDHS of
2013.[3]

4. Geriatric burden in Africa
• Nearly, 70% of older persons in the world
currently live in developing countries[1] and this
proportion is expected to increase to 80% by
2050.[1,2]
• In 2013, global health Africa shared report of the
Global Age Watch Index [4], on the quality of life
of older people in 91 nations
– South Africa was the highest ranked African nation at
number 65 while Ghana, Morocco, Nigeria, Malawi,
Rwanda and Tanzania came in at numbers 69, 81, 85,
86, 87 and 90 respectively

5. • Another African survey [5] showed that in 11
of 15 African countries, the proportion of
older people living in poverty was higher than
the national average.
Geriatric burden in Africa

6. The burden of aging on health care system
• The elderly form most part unemployed and
demographically dependent population
• Also account for a disproportionately large
fraction of healthcare utilization due to age
related illnesses[4,6]
• Lack health insurance and pay out of pocket
• Yet do not have health needs prioritized at
family, community, or national levels.

7. Identification of problems…
• ”Carelessness!’’

8. Identification of problems…
• Ineffective and inaccessible health insurance policy
• Unreliable gratuity, pension and other retirement
benefits
• Huge out of pocket expense on health
• Dependency and poverty
• Poor health seeking behaviors
• Poor awareness o aging and care of the needs of the
aging
• Poor structured training of health workers on geriatrics
• Near absence of geriatric programming

9. • Way forward

10. Making health care acceptable to the elderly;
adopting culturally sensitive models
• Residential home of care has been arguably
said not to suite the African culture where
there is a wide belief that sending an
elderly/grandparents to a residential home
like nursing home is a sign of irresponsibility
and abandonment.
• What other more acceptable (culture
sensitive) models are there???

11. Option 1- Day care centers
• Day care center is very culture sensitive in the
African setting which do not readily accept elderly
persons being permanently confined to institution
like total abandonment
• Clients visit for enrollment who wish for day in day
out stay
• To reach larger population, the day care center
will be built or established in community hospitals
which are already within communities even at
rural areas

12. Option 2- home based care
• Identification and enrolment of home
bound elderly by partnering heath
facilities supported by implementing
partner
• Provision of home based medical service
for the incapacitated elderlies as
applicable via community health care
workers and volunteers in partnering
hospitals (geriatric clinic and centers)

13. Option 3-Community based program
• Community programs to raise
awareness on aging and related
care
• Platform to identify first level
assessment of a condition
• Mobilizes community for
enrollment of elderly into health
programs
• To be done in partnership with
host community and health
center

14. Making health care accessible to the elderly –
through geriatric clinics/centers and geriatric
programming
• Instituting Geriatric specialist tertiary hospitals
• Instituting geriatric clinic in community hospitals
• Pre service and In service training of health care
workers in geriatrics

15. Making health care affordable to the
elderly- The role of NHIS
• Although the latest national health act of
Nigeria captures the elderly as vulnerable
group due to receive free basic health care,
the national health insurance scheme do not
cover them as such
• Because the elderly comprises of retired
dependent population, more often than none,
they do not belong to the formal programs of
the NHIS

16. Making health care affordable to the
elderly- The role of NHIS
• Therefore, the elderly fall into category of
beneficiaries of the informal health insurance
programs thus;
– community based social health insurance
program (CBSHIP) and
– Voluntary contributory social health insurance
program (VCSHIP)

17. Definition
• Community Based Social Health Insurance is a
non-profit health insurance program for a
cohesive group of households /individuals or
occupation based groups including retirees and
elderly
Membership
• This is voluntary and open to all residents of the
participating communities/occupation based
groups (including retirees)
CBSHIP for the elderly in Nigeria

18. Registration-
• registration of enrollees is by technical
facilitators and Board of Trustees (BOTs) from
community leaders and members
• Communities/occupation based groups shall
have at least 50% of members willing to
participate (or a minimum of 1000 members).
CBSHIP for the elderly in Nigeria

19. Benefit package-
• The benefit package shall reflect preventive,
promotive and curative components of health
care delivery. It shall aim at minimum primary
and secondary curative care such as basic
assessment, infections, infestation, minor
ailments, MCH
CBSHIP for the elderly in Nigeria

20. Benefit package-
• In this case, the epidemiology of aging will be
selected as benefit coverage so as to maximally
benefit the target population. Benefit package
could be negotiated to include assessment,
diagnosis and management of hypertension,
arthritis, and diabetes mellitus.
• However, CBSHIP excludes ophthalmic evaluation
and management (a major need of the elderly)
CBSHIP for the elderly in Nigeria

21. Contribution/Premium
• This shall be actuarially determined flat rate
fee and paid in cash monthly or seasonally in
advance.
• At least 1000 enrollees are needed to start the
program at cost of 2,500 ($5) for 6 months or
5000($10) for 12 months.
CBSHIP for the elderly in Nigeria

22. Donations and Partnerships
• Project managers may seek for
donations/grants by way of formal
launching/fund raising events, or by targeting
individuals, governmental and Civil Society
Organizations, including private companies,
with the aim to boost the financial base of
these schemes.
CBSHIP for the elderly in Nigeria

23. Management models for CBSHIP
NHIS (REGULATOR)
BoT/Program Managers ( at least 6 leaders in the community)
(Responsible for the day-to-day
program management, engagement with stakeholders,
medical auditing, QA, etc)
Community Members (Pay regular
contributions, give feedback to
program managers,
access health care services feed
back to PM)
Health care facilities (Provides health
care services to enrollees and receive
payment
from Program Managers regularly
feedback to PM)
Technical Facilitator (eg ME projects)
(provides initial & on-going technical support to BoT
as programme managers)

24. VCSHIP for the elderly in Nigeria
• Definition- Voluntary Contributors Social
Health Insurance Program (VCSHIP) is health
insurance that is taken up and paid for by or
for willing individuals like an elderly persons. It
is a program designed for those who are not
currently covered by any of the NHIS programs

25. Membership
• Membership shall be voluntary and shall cover
interested individuals and retirees not
currently covered by any of the NHIS prepaid
programs.
VCSHIP for the elderly in Nigeria

26. Financing/payment
• The program shall be financed from
contributions made by interested individuals.
• The contribution rate actuarially determined
to be 15,000 naira (30 dollars) only per person
annually
• This can be paid by individual (eg elderly
person) or by a sponsor through
funding/grants.
VCSHIP for the elderly in Nigeria

27. Benefit Package
• Out-patient care (including drugs and consumables)-eg
hypertension, DM, arthritis
• Routine immunization
• Surgical procedures
• Internal medicine
• HIV/AIDS (management of Opportunistic Infections)
• STIs
• Mental Health
• Obstetrics and Gynecology
• Ophthalmology
• Emergency care
VCSHIP for the elderly in Nigeria

28. Administration and Management
• This is a social health insurance market and
managed by Health maintenance
organizations (HMOs) as a form of social
protection and is properly regulated through
legal, fiscal or bureaucratic procedures with
NHIS supervision of overall implementation.
VCSHIP for the elderly in Nigeria

29. Fund Management
• NHIS is to oversee the contributions paid by the
voluntary insured persons. Voluntary contributors
registered with HMOs shall remit their
contributions to the NHIF through the HMOs.
• And Health care Facilities under the Scheme
where clients access care shall be paid by
capitation, fee for service, per diem or case
payment
VCSHIP for the elderly in Nigeria

30. VCSHIP for the elderly in Nigeria
NOTE!
• Geriatric program IPs MUST oversee the
quality of service provision of HMOs and
partnering hospitals to clients

31. Conclusion
• Growing population of elderly persons in
Nigeria and Africa is envisioned to result to
burden on already overwhelmed health care
system
• Current level of planning for care of the aging
population in Africa is below expectation
• Plans for their health care must consider it’s
acceptability, accessibility and affordability to
be effective

32. Conclusion
• Day care, home based and community based
programs/models- as against westernized and
institutional confinement- for the elderly
seem more culturally sensitive and acceptable
in African context

33. Conclusion
• Institution of geriatric centers and geriatric
clinics in already existing hospitals- coupled
with training of health care workers in
geriatric care- makes health care more
accessible to the elderly population

34. Conclusion
• Leveraging on enrollment of elderly persons
into NHIS of countries to reduce out of pocket
expenses is a gold mine that must be cashed
into to make health care affordable for the
elderly

35. Thank you

36. References
1. World Population Ageing 2013. United Nations Department of Economic and Social
Affairs, Population Division Website. Published. 2013. [Last accessed on 2015 Sep
16]. Available from:
https://www.un.org/en/development/desa/population/publications/pdf/ageing/
WorldPopulationAgeing2013.pdf .
2. Peltzer K, Williams JS, Kowal P, Negin J, Snodgrass JJ, Yawson A, et al. Universal
health coverage in emerging economies: Findings on health care utilization by
older adults in China, Ghana, India, Mexico, the Russian Federation, and South
Africa. Glob Health Action. 2014;7:25314. [PMC free article] [PubMed]
3. National demographic heath survey. 2013
4. Global health Africa. https://globalhealthafrica.org/category/elderly/ Accessed May
2017
5. Global Aging. http://www.global-ageing.eu/agafrica.html, Accessed May 2017
6. Palangkaraya A, Yong J. Population ageing and its implications on aggregate health
care demand: Empirical evidence from 22 OECD countries. Int J Health Care
Finance Econ. 2009;9:391–402. [PubMed]

37. Acknowledgement
• Mission to Elderlies Project, Renewal Health
Foundation Nigeria
• Geriatric care and vulnerable support Initiative
• Joint life savers foundation
• Center for Clinical care and Clinical Research
Nigeria (CCCRN)
• World Health Organization