Abstract
Ghana has ratified almost all international legislative instruments aimed at enhancing the welfare of the elderly. At the domestic level, the country has formulated and implemented policies that seek to improve the lives of elderly. Using mainly secondary data and also analysis of research conducted at Ga Mashie in the Greater Accra Region, the paper provides a narrative review of the existing legal framework and the role of state institutions in advancing the interest and welfare of the aged. Two flagship programs, the Livelihood Empowerment Against Poverty (LEAP) and National Health Insurance Scheme (NHIS), both of which have components intended for the vulnerable including the aged, were evaluated. The most striking similarity in both the LEAP and NHIS interventions (and also the newly introduced EBAN project) is the exclusion of the elderly between the ages of 60 and 64 from qualified beneficiaries. While people within that age bracket are constitutionally classified as elderly, interventions meant for the elderly do not cover them. Also, insufficient funds, poor targeting, and inaccurate implementation and evaluation of data make otherwise well-designed programs intended for the elderly lose their focus and merit. We make three recommendations. First, there is a need for a downward review of the age criteria for beneficiaries of social intervention programs meant for the aged. Second, a mechanism should be developed, going forward, to enable the elderly that have worked in the informal sector throughout their lives, to contribute to and also benefit from the SSNIT pension scheme. Finally, an adequate and reliable database on the elderly should be developed to help improve targeting, implementation, and monitoring of existing social protection programs aimed at the aged.
Introduction
The African population is aging rapidly. According to Nabalamba and Chikoko (2011:2), “As of 2010, 36 million elderly people aged 65 years and over accounted for 3.6% of Africa’s population, up from 3.3% ten years earlier. In 1980, 3.1% of the population was elderly aged 65 and above and there has been a steady increase during the last forty years.” There is no end in sight to this rapid population growth of the elderly since it is projected that they could account for 4.5% of the population in Africa by 2030 and nearly 10% by 2050 (Nabalamba and Chikoko, 2011). Population growth of the elderly in Ghana is consistent with the continental level increase. According to the Ghana Statistical Service (2013) the “population of the elderly has increased by more than seven-fold since the 1960 census, rising from 213,477 in 1960 to 1,643,381 in 2010” (p. iv). There are more female elderly people (56%) compared to male (44%) which is a feature of global aging (GSS, 2013). The majority of the elderly, about 58.5%, are economically active and are also self-employed mostly in agriculture (63.1%), sales work (13.3%), or craft and related trade (8.4%) (GSS, 2013). These three occupations form the major source of employment for the elderly and about 84.4 per cent of them engage in these activities. However, a small percentage of them are professionals (2.7%), managers (2.2%), and technicians or associated professionals (1.3%). These percentages suggest that the majority of the elderly are engaged in low earning employment (i.e., private informal sector activities compared to a more formalized high income earning jobs). This has the potential of increasing their vulnerability as they age rapidly since most of these jobs demand physical strength and continuous time commitment usually lacking at an older age.
Traditionally, the family provided the social support and security needed to survive during old age. The social support role of the traditional African family system is widely expressed in the daily proverbs and folklore of the people. Apt (2000) notes that in Ghanaian society the generational tradition of burden sharing is captured in the saying that “when your elders take care of you while you cut your teeth, you must in turn take care of them while they lose theirs” (p. 2). This value system is not peculiar to Ghana. In some African communities, it coalesced into national struggle watchwords and influenced development strategy. The concept of ubuntu in South Africa, harambee in Kenya, urukwavu in Rwanda, and ujaama in Tanzania are just few examples. These demonstrate that mutually shared responsibility and assistance constitute the moral basis for social protection in Africa. Indeed, personhood in Africa is conceived from a communal point of view and a person’s uniqueness is measured not only by the community that the person came from but also by his or her connection with others in that community (Battle, 2007; Mbiti, 1967).
However, difficult economic conditions, coupled with other factors such as urbanization, have undermined the family’s position as the ultimate welfare provider and have further weakened the traditional welfare system (Nukunya, 2003). The burden of care and protection is now gradually being taken over by the state and non-state institutions (including religious and philanthropic groups) and the family only supplement these institutional provisions. The ability of the state to provide for the elderly is dependent on the strength of the economy. Even though developed countries have better performing economies that may support social protection interventions for their elderly population, their population growth is far slower than developing countries that usually have weaker economies (GSS, 2013).
This paper aims to explore existing legislations and policies that relate to the elderly in Ghana and the level at which they meet their needs. It argues that in spite of the numerous existing legislations and policy frameworks regarding the welfare of the elderly, the country still lags behind in implementing them. The paper provides evidence to support this position by examining two prominent policies (the Livelihood Empowerment Against Poverty and the National Health Insurance Scheme) that target the elderly as well as other social groups. The paper is divided into three major sections. The first section examines the various ways in which the concept of aging is conceptualized and its impact on policy formulation in the country. The second section is a narrative review of what has been done in the country to advance the interest and welfare of the aged. And the final section evaluates the issue of implementation and the challenges therein using the Livelihood Empowerment Against Poverty (LEAP) program and the National Health Insurance Scheme.
Conceptualizing Aging in Ghana
According to the Ghana Statistical Service (2010) the “… elderly refers to a category of adults who have attained advanced ages, 60 or 65 years” (p. iii) and an individual is said to be “… aging when he/she attains ages that are classified as old ages” (p. iii). Demographically, the aged is used to refer to persons within the age bracket of sixty to sixty-five years. However, this age bracket varies across countries in both developed and the developing world. Life expectancy in developed countries is often high compared to developing countries and these results in differences in retirement from active economic activities in each world. In Ghana for example, the retirement age is 60 years and people are considered elderly once they retire while in other developed countries. Aging may also be seen as the “process by which the elderly or older persons constitute a higher proportion of the total national population than at an initial period” (Weeks, 2012). For example, the Ghanaian population is largely seen as youthful since children form over 40 percent of the national population while the aged are made up of only 5 percent (GSS, 2013). The Ghanaian example is reflective of most national populations in sub-Saharan Africa. Comparatively, persons defined as old in Low- and Middle-Income Countries (LMICs) constitute fifteen percent of the total population with France, Germany, and Italy having about twenty-five percent of their population statistically defined as old (Nabalamba and Chikoko, 2011).
In Ghana, the definition of aging seems to tilt more to the age brackets of 60 or 65 years than to the number of people in the population that are aging. The aged is defined as people above the age of 60 and there are different categories in the literature. Weeks (2012) makes a distinction between the “young old” and the “old old” based on their relative strength and ability to perform tasks that require physical involvement. While the “young old” refers to the age brackets of 65–74 years, the “old old” falls within 75 years and above. To further complicate the concept, the Nigerian National Population Commission (2004) classified the elderly into three categories: namely, the “young old” classified within the age brackets of 60–64 years; the “old old” classified within the age brackets of 75–84 years; and the “oldest old” within the age brackets of 85 years and above.
These classifications inform policy formulation and implementation and a wrong classification could have disastrous implications. For example, persons classified as “young old” and “old old” may still be young and active and be able to work. However, because the definition restricts the age limit to 60 (i.e., in the case of Ghana), policies that affect “oldest old” affect the active “young old” too. Given the Ghanaian cultural system and role assignment, persons beyond the age of sixty are still engaged in both productive and reproductive caregiving activities including the bathing of newborn babies in their communities and attending to delivery of children, and many are themselves heads of their homes (GSS, 2013). Therefore, the definition and conceptualization of older people should be cognizant of the gendered roles played by men and women in the community and not just focus on age.
Existing Social Protection Support for the Elderly in Ghana
In Ghana, the history of social protection policies for the aged dates back to 1965 as a result of the implementation of the Social Security Act, in which lump sums were drawn from an established Provident Fund and paid invalidity and survivors’ benefits to the aged (Abebrese, 2012). Then in 1965 as a result of the implementation of the Social Security Act (Act 279), the National Provident Fund Scheme was set up and this became the framework for a more Ghanaian social security scheme (Darkwa, 1997). The Social Security Act gave way to the Social Security Law in 1992 and there was a change from the Provident Fund into a Pension Scheme. Under the Social Security Law of 1992, the payment of lump sum benefits was converted into a scheme, which allows periodic monthly payments to be made to beneficiaries until their death (Kumado, 2007). This arrangement was not only modelled along insurance principles but also involved inter-generational resource transfer (Kumado, 2007). The Pension Scheme covered employed workers in the formal sector and also had voluntary coverage for self-employed persons and non-employed formerly insured persons (ibid).
Agblobi (2011) observes that three different types of retirement benefits schemes were already in operation before the passing of the new pension law: the CAP 30 scheme, the Social Security and National Insurance Scheme (SSNIT), and the Ghana Universities Staff Superannuation Scheme (GUSS). The CAP 30 retirement benefit scheme was established by the Pensions Ordinance of 1946 by the British Colonial Government. The primary reason for establishing the scheme was to provide pensions for officers working in the civil service and the armed forces in British West African Colonies (Yankah, 2008; cited in Agblobi, 2011:20). The main aim of the CAP 30 followed this idea of maintaining discipline in British West African Colonies—including the Gold Coast, Nigeria, British Togoland, Sierra Leone and the Gambia—and therefore benefits after retirement were not automatic. The Ghana Universities Staff Superannuation (GUSS) was established on January 1, 1976, and amended under the respective Acts of the councils of member institutions. It is a pension scheme coordinated by the Committee of Vice Chancellors (CVC) and administered by a Management Board. The GUSS is designed for University Teachers and Research Fellows, University Administrative, Library, and Professional Staff of a status comparable with that of University Teachers (Agblobi, 2011).
A statutory body known as the Social Security and National Insurance Trust (SSNIT) manages Ghana’s pensions. Established in 1972 under National Redemption Council Decree (NRCD) 127, the Trust assumed its current role as a social insurance pension scheme in 1991. Prior to this development, the Trust administered a Provident Fund Scheme, which was jointly managed by the Department of Pensions and the State Insurance Corporation (SSNIT, 2016). The operation of SSNIT is governed by the National Pensions Act 2008 (Act 766), which calls for a three-tier Pension Scheme with the following contribution rates: the employer contributes 13% of the worker’s basic salary while the worker contributes 5.5% of his or her basic salary. Beneficiaries of this scheme were entitled to three basic benefits: old age pension, invalidity pension, and death-survivors payment. However, several new measures were introduced into the scheme with the launching of the National Social Protection Strategy (NSPS) in 2007. In one of these measures, the National Pension Regulatory Authority (NPRA) was established to oversee the implementation of the New Pension Act in 2010. The structure of the Pension Scheme was also expanded to embrace the three-tier scheme. These included a mandatory basic national security system (SSNIT), a mandatory fully funded and privately managed occupational pension scheme, and a voluntary fully funded and privately managed provident fund and personal pension scheme. The advantage of the three-tier scheme is that it captures workers in the informal sector. Workers in the sector who wish to be covered by the scheme are required to make a voluntary monthly contribution of 16.5% of their earnings. Workers under the informal sector have two different accounts: the retirement and the personal savings accounts. The personal savings account helps informal workers access benefits before their retirement. In 2008, older people constituted 6.6% of the Ghanaian population (1,465,200). Only 4% of the elderly population (58,000 individuals) were on SSNIT pension (Doh et al. 2014).
Beyond the established pension schemes, there are two more recent social protection initiatives that target the aged—the National Health Insurance Scheme (NHIS) and Livelihood Empowerment Against Poverty (LEAP). The NHIS provides free healthcare to individuals aged 70 and above. This qualified age for NHIS beneficiaries is problematic. In Ghana, the retirement age is sixty and the amount of money pensioners receive is low side (although this varies with the amount they contributed when they were in active service). Further, it takes most retired pensioners several years to be able to complete the necessary procedures that allow them to access their pensions. Therefore, the first five years of the average retiree (i.e., 60–65) is very crucial for their survival, but unfortunately people within this age bracket do not get free NHIS until they are aged 70. It is estimated that only two percent of older people in this category are registered for the NHIS (Aryeetey, 2011; GDHS, 2008). Aging raises the risk of complex health problems. Recent research highlights the increasing burden of chronic non-communicable diseases among the aged, with a rising number living with co-morbid and multi-morbid conditions (Anum and de-Graft Aikins, 2014; Ayernor, 2012; de-Graft Aikins et al. 2013). Thus, limited access to NHIS increases the catastrophic financial and medical impact of long-term illness for the aged. There has been a trend of poor access to healthcare by the elderly due to the high costs of medical care and institutional barriers such as poor geographical access and poor communicative practices by health professionals (Apt, 2002). The LEAP aims to provide cash grants for the elderly who are also needy. The program, like the pension schemes and NHIS, reach a very limited number of eligible beneficiaries. In 2008, only 6,041 elderly individuals (constituting 0.4% of the elderly population) received LEAP cash grants. In 2009, the program reached 13,811 elderly people across 80 districts. This still represented only just less than 1% (0.94%) of the elderly population. According to the Ministry of Gender, Women, and Social Protection, about 145,894 households have registered for LEAP across the country. Though there is no disaggregated data to show how many of these registered memberships constitute the elderly, it nonetheless shows an expansion in the scheme.
Existing legal and policy frameworks
The concept of social protection, broadly conceived, is thought to have emerged from the early works of the ILO and is also seen as part of the 1948 Universal Declaration of Human Rights (UDHR) that guarantees citizens the right to social security (Cook and Kabeer, 2009). Indeed, Article 22 of the Universal Declaration of Human Rights (UDHR) states “everyone, as a member of society, has the right to social security.” The UDHR is one of the major international legal instruments that made an implicit reference to the rights of the elderly in a state’s provision of social security. The Madrid Plan of Action on Aging (2002) initiated an actionable framework known as the Madrid International Plan on Action on Aging (MIPAA) to help create opportunities for, and address the challenges associated with aging.
Further, the United Nations Plan of Action on Aging (1982), the United Nations Principles for Older Persons (1991), and the United Nations Proclamation on Aging (1992) all reinforce the need to protect and advance the rights and interests of the elderly. These international legal instruments are augmented by some international conventions that are not specifically geared towards the aged but invariably contain provisions that protect their rights. Some of these instruments include the United Nations Universal Declaration on Human Rights (UDHR, 1948); the African Charter on Human and Peoples Rights (1986); the International Covenant on Civil and Political Rights (ICESCR, 1966); the United Nations Declaration on the Right to Development (1996); the Convention on the Elimination of Racial Discrimination (CERD, 1965); the Convention on the Elimination on all forms of Discrimination against Women (CEDAW, 1997); the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (CAT, 1984); the International Labour Organization Convention, and the United Nations Rules on Equalization of Opportunities for Persons with Disabilities (1996) as presented in Table 1.
Legal Instruments Related to the Elderly
The Madrid Plan of Action
The Madrid Plan
The Madrid Plan committed Governments, including that of Ghana, to take three actions that could help address the challenges faced by the elderly. The first action seeks to commit governments to providing an enabling political environment that is supportive for enhancing the welfare of the aged and includes the following decisive measures:
the provision of housing and living environment;
care and support for caregivers;
preventing the neglect, abuse, and violence against the aged; and
creating a positive image of aging.
The second action required from governments include advancing the health and well being of the aged by doing the following:
promoting the health and well being of the aged throughout their lives;
providing universal and equal access to health care services;
providing support for older persons living with HIV/AIDS;
the training of healthcare providers and health professionals;
providing the mental health needs of older persons; and
providing for older persons with disabilities.
The third and final action involves governments providing developmental space for the aged by doing the following:
advancing their active participation in societal development, work, and labour force;
rural development, migration, and urbanization;
providing the aged access to knowledge, education and other related trainings;
building inter-generational solidarity;
eradicating poverty; and
providing income security, social protection, and social security for the elderly.
Source: The Ghana National Ageing Policy (2010:44)
At the state level, the National Aging Policy (2010) provides an overarching legal and policy framework for dealing with the aged. It draws broadly from the legal provisions in the 1992 Constitution of Ghana. Article 37(6)(b) of the Constitution states “the State shall provide social assistance to the aged such as will enable them to maintain a decent standard of living.” The National Aging Policy has the basic goal of achieving “… 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” (p. 11). Other provisions in the 1992 Constitution of Ghana provide support to this provision. Article 37(2)(b) of the constitution indicates that the “State shall enact appropriate laws to assure the protection and promotion of all other basic human rights and freedoms, including the rights of persons with disability, the aged, children, and other vulnerable groups in the development process.” Chapter Five Article 12(2) entitles all citizens to enjoy their basic rights and freedoms regardless of their race, color, creed, or religious affiliations, and this applies to older persons as well. Chapter Six Article 36(6) guarantees equal economic opportunities to all citizens and further provides for the “… full integration of women into mainstream … economic development” of their country. While Chapter Fourteen Article 199(1) provides for the age of retirement from public service, Chapter 199(3) guarantees the payment of non-taxable pension to retired public service workers.
Other legal frameworks that support the elderly in Ghana include the Persons with Disability Act, 2006, (Act 715), and the Mental Health Act 846. Ghanaians with disabilities face many challenges every day, including that of poverty, exclusion, and stigma (de-Graft Aikins, 2014). Disaggregated data for the elderly in the recent Population and Housing Census (2010:65) indicates that:
More than a tenth (12.3%) of the elderly has one or more kinds of disability, compared to 2.3 percent of the population aged less than 60 years. The proportion with disability increases with advancement in age, the proportion of the elderly aged 80 years and above with disability is more than twice (18.5%) that of the 60–64-year-olds (8.1%). Disability is slightly more prevalent among the rural dwellers (13.0%) than among their urban counterparts (11.5%). The commonest types of disability reported among the elderly include sight (29.0%), physical (18.4%), emotional (13.4%), intellectual (11.0%) and hearing (10.8%).
While visual, physical, and hearing disabilities, as disabilities listed by the World Health Organization (WHO), are often recognizable, intellectual and emotional disabilities requires an explanation. Emotional disability impacts on an individual’s ability to effectively recognize, interpret, control, and express one’s fundamental emotions (Jacobson, et al. 2007). Intellectual disability is a fundamental limitation in both the intellectual functioning and the adaptive behavior of the elderly population. Intellectual disability may affect the general mental capacity of the aged including learning, reasoning, and problem solving skills (Jacobson, et al. 2007). These are very common among the elderly population and that age group may be largely associated with stroke and other neurodegenerating conditions (Anum and de-Graft Aikins, 2014).
Additional provisions for the elderly include those found in the Interstate Succession Law, 1985 (PNDC Law 111), which has provided valuable support to elderly widows. The Social Security Law, 1991 (PNDC Law 247); the Criminal Code (Amended) Act, 1998 (Act 554), the Labor Law, 2005 (Act 715), the National Population Policy (1994), and the National HIV/AIDS Policy (2002) all have provisions that enhance the welfare of the aged in a specific way. Table 2 provides more details on some of the legislations.
Legislations that Protect the Aged
In addition, the institutional framework for policy implementation specifies the role of government, family and community, the private sector, employers and organised labor, older persons’ groups and associations, non-governmental organizations, civil society organizations, and development partners in dealing with the aged (NPC 2014).
The National Health Insurance Scheme and the Aged
The World Health Organization (WHO) report on global aging and health (2012) recognizes that aging populations will have a significant impact on the health policies and programs of many countries. Consideration for the aged in Ghana’s health sector has a history that dates back to the postindependence era. After the attainment of independence in 1957, the socialist strategy of the Nkrumah government included free health care for a majority of the populace, including the aged. Substantial investment in healthcare financing from the country’s tax revenue saw the introduction of exemptions (Agyepong and Adjei, 2007). However, this was short-lived due to deteriorating economic conditions and also some citizens taking advantage of the arrangements put in place following the introduction of the exemptions. As such, by 1972, under the Acheampong-led government, out of pocket payment was introduced as a way of curtailing the abuse of the exemption system. This removal of the exemptions led to the introduction of the payment of user fees in the health sector (Agyepong and Adjei, 2007).
The introduction of user fees into the health sector continued to witness upward adjustment. By 1983, following the stagnation of the Ghanaian economy and the shortage of drugs and other medical supplies, Ghana adopted the World Bank and IMF economic recovery programs. In 1985, user fees increased even more significantly following the passage of the Hospital Act (Badasu, 2004). The 1990s continued to witness contradictory policies in the health sector. The first was the introduction of the “cash and carry” system to help health service centers recover the costs of drugs. The second was the introduction of yet another exemption including concessions for the aged (Derbile and Van der Geest, 2012; Laing and Gobah, 2011). In the years that followed, various insurance schemes were developed and piloted across the country with the aim to provide solutions to the existing barriers that limited the number of persons accessing health services in Ghana (Derbile and Van der Geest, 2012). These schemes also had exemption components, which catered to the health needs of the aged.
In 2003, Act 650 was passed uniting the various types of health insurance schemes in Ghana and gave it legal backing through the National Health Insurance Scheme (NHIS). There are exemptions implemented under the NHIS, which favor children under 18 years, pregnant women, the aged, and public servants in the payment of premiums. Subscription and payment of premiums also vary under the scheme, with consideration being given to low income earners, public sector workers, and individuals over 70 years of age who do not have to pay at all.
The introduction of the NHIS has generated academic debate about its successes and challenges, especially in relation to the elderly. Some studies have indicated that the challenges encountered in the implementation of NHIS outweigh the benefits and these affect all users including the aged (Jehu-Appiah et al. 2011). Since the inception of the program, the Universal Access to Health Campaign notes that half of the numbers of people registered for the Scheme are unable to renew their cards after it has expired. It further finds that 65% of Ghana’s population still relies on the “cash and carry” system. Also, the study by Jehu-Appiah et al. (2011) indicates that the NHIS cardholders are sometimes asked to pay for the health care services while some are even denied the services in some facilities. Further, financial barriers still remain a major challenge to Ghanaians accessing healthcare more especially as the NHIS covers less costly drugs and late disbursement to other stakeholders of the Scheme, including pharmacies and other partner health centers (Asante and Aikins, 2008).
LEAP and the Aged
In this section, we examine implementation of the Livelihood Empowerment Against Poverty (LEAP), a social intervention program that targets the poorest and most vulnerable of all ages. LEAP is a social cash transfer program, which provides cash and health insurance to extremely poor households across Ghana to alleviate short-term poverty and encourage long-term human capital development. LEAP began expanding gradually in 2009 and 2010, and has reached 145,894 households by the end of 2015. The Upper West Region has the highest number of household registration (31,631); followed by the Northern Region (29,729); then the Upper East, Volta, and Eastern Regions with 20,800, 11,620 and 10,875 respectively. Greater Accra had the fewest registered households (6,371), followed by Western and Central regions with 7,561 and 8,522 respectively (MoGSP, 2015).
The program is funded from general revenues of the Government of Ghana (50 percent), donations from the United Kingdom Department for International Development (DfID), and a loan from the World Bank, and is the flagship program of its National Social Protection Strategy. The Department of Social Welfare (DSW) under the Ministry of Gender, Children, and Social Protection (MoGSP) implements LEAP. Eligibility is based on poverty status and having a household member in at least one of three demographic categories: orphaned or vulnerable children (OVC), the elderly poor (65 and older), or a person with extreme disability who is unable to work. One of the most celebrated achievements of LEAP vis-à-vis the elderly is the fact that they can access free healthcare by using free health insurance provided for by the National Health Insurance Scheme even though the NIHIS cuts out elderly persons younger than 64 years. This provision allows older persons aged 65 years and above who are registered on the LEAP cash transfer program an exemption from the payment of registration fees as premiums to access health services under the NHIS (NPC 2014). This is an improvement in terms of access to healthcare by the elderly compared to the era of out-of-pocket payments. There is still room for improvement notwithstanding this success. For example, those in the elderly population who have special needs, such as chronic illness or serious disability, and who are not catered for by the National Health Insurance Scheme could be allowed to access free treatment under the LEAP program. This would not only be innovative but also strengthen the complementarity of the two interventions. This is deemed critical because the elderly population (i.e., those who are 65 and above) already enjoys free medical care under the NHIS. Thus, LEAP could take this further by introducing packages for those in that population who have specific needs not catered for by the NHIS.
From April 2010 to April 2012, LEAP households received between GHS 8–15 (US $2–4) every other month depending on eligible beneficiaries per household. A household with one beneficiary gets GHS 8 (US $2), and those with two beneficiaries get GHS 10 (US $2). Those with three beneficiaries get GHS 12 (US $3), and those with four or more get GHS 15 (US $4). There has been an improvement in the amount of money given to beneficiaries since the second half of 2012. Families with just one beneficiary now get GHS 48 (US $13), those with two beneficiaries get GHS 60 (US $16), those with three get GHS 72 (US $19), and those with four or more get GHS 90 (US $24). Although this is an improvement, the increment is still low. For example, it costs a LEAP beneficiary household of six people an average of GHS 10 (US $2.5) to prepare a basic staple meal. Coupled with the minimum daily wage in the country, pegged at GHS 7 (US $1.8), current hikes in utility prices as well as fuel and transportation; it becomes difficult to sustain oneself and other family members on this amount.
One good thing about social protection policies of the kind like LEAP is that there should always be an exit strategy. It is therefore assumed that beneficiaries could spend and save some of the money they receive and start business with it later. The thinking behind the program seems impossible to achieve under difficult economic circumstances. A recent study conducted on the impact of social policy interventions on the lives of the people of Ga Mashi (a twin town consisting of two communities: Jamestown and Ussher Town in the Accra Metropolitan Assembly) attest to the difficulty poor communities go through in utilizing LEAP money in difficult economic times. Characterized by high population density and low socio-economic status, the average monthly household income in Ga Mashi is only GHC 126.13 (US $78.83) (de-Graft Aikins, et al. 2014). This places the communities in the fourth and lowest income class within the Accra Metropolitan Area (de-Graft Aikins, et al. 2015). Even though the Ga Mashi community is noted to have chronic problems including poor spending habits (de-Graft Aikins, et al. 2015), a troubled economy reduces the value of the money they receive and what that money could be used for.
In an impact evaluation carried out on LEAP between April 2010 and April 2012, by Handa et al. (2013), contrary to the previous evidence from the Ga Mashi study, there was an increase in food security among LEAP households. However, it is worth noting that there are likely explanations for the occurrence of this contradictory finding. The Handa et al. study held other factors constant and further points out that the positive findings about LEAP may not be attributable to the program alone. Further, the study does not disaggregate the outcome levels for elderly persons who constitute almost 20% of the program’s beneficiaries (Handa et al. 2013). Nevertheless, this evaluation reveals that LEAP households were significantly happier. It indicates a 16-percentage point increase in happiness, highlighting the positive impacts of the NHIS coverage, children’s health and schooling, and the ability to pay loans and accrue savings (Handa et al. 2013). It further finds that LEAP has led to a significant increase in the likelihood of household savings (11 percentage points), and a significant increase in gifts received. LEAP has also had an impact on debt repayments and reduced loan holdings, particularly among female-headed households (Handa et al. 2013).
There have been quite a number of challenges with the implementation of the LEAP program, which the study points out. These challenges have both direct and indirect implications for the aged. They include the inconsistency in payment. Over the 24-month evaluation period, households received only 20 months’ worth of payments (Handa et al. 2013). Since consumption is driven by permanent income, there was no positive impact on consumption according to the evaluation report. This finding from the impact evaluation is supported by evidence gathered in the study by de Graft-Aikins et al. (2015). The latter study suggests that LEAP cash grants are not sufficient and irregularly disbursed, ranging from GHC 24 (approx. US $10) to GHC 45 (approx. US $19). Grants are often not disbursed for months although beneficiaries receive accumulated funds when funds are delayed (de-Graft Aikins, et al. 2015:88). The differences and yet similarities in findings between the de Graft-Aikins et al. study (2015) and the Handa et al. study (2013) show that LEAP, as a social intervention program, might have improved the lives of some, but not all of the people who are enrolled in it. The attempt to evaluate impact is commendable, but there is a need for more research, based on disaggregated data, to measure the extent of benefits from the program for the elderly.
The program is also saddled with the challenge of poor targeting. This challenge is largely attributable to inadequate or inaccurate household data. There is thus poor targeting resulting from exclusion and inclusion errors. Related to inaccurate data on the program, there is also the paucity of data on implementation and evaluation, which have so far been in fragments. Thus, rigorous impact assessments of the program indicating outcome levels for the various beneficiary categories are currently nonexistent. This poses further challenges for the identification of areas that need to be strengthened or completely reformulated.
Conclusion
This paper has provided a narrative review of the existing legal framework and the roles of the state institutions in advancing the interest and welfare of the aged. Two flagship programs, the LEAP and NHIS both of which have components intended for the vulnerable including the aged, were evaluated. These two programs have had some successes but at the same time have been saddled with a myriad of challenges, some of which include insufficient funds, poor targeting, and inaccurate implementation and evaluation data.
The evidence gathered from this study, both practical and theoretical, indicate the willingness of the government of Ghana to introduce initiatives aimed at alleviating the numerous challenges that the Ghanaian elderly face. Some of these interventions are anchored on the existing domestic and international legal framework. However, the most striking similarity in the two interventions reviewed in this paper (LEAP and NHIS) is the exclusion of the elderly between the ages of 60–64. As stated at the beginning of this paper, people within that age bracket are classified as the “young old” in reference to their relative strength and ability to carry out tasks designed for persons outside the elderly bracket. In some specific professions (including teachers at public universities and some sectors within the health system) where expertise remain a challenge, such people are given retirement contracts to continue providing valuable services. Yet, this is not a statutory requirement and such arrangements differ among employers and often depends on the requisite skills that these “young olds” posses. This issue needs a policy attention. It is prudent that measures intended to help the poor covers all persons constitutionally defined as such. It is unfair if there seem to be positive discrimination against some groups within the generic brackets of the elderly.
Further, lack of disaggregated data makes it difficult to specifically point out the number of elderly beneficiaries of the interventions discussed. However, the LEAP initiative has the broader aim of alleviating poverty and therefore will necessarily target regions and districts that are relatively poorer. Identifying the poorest of the poor is practically and conceptually burdensome. This is often the result of the subjective and multi-dimensional nature of the definition for poverty (Aryeetey et al. 2013).
The analysis also raised some challenges faced by pensioners who are based in the informal sector. Though the new three-tier pension scheme (currently being implemented) makes provision for members who work in the informal sector to contribute to SSNIT, it is still difficult to appropriately capture them. The NHIS does not also cover the elderly between 60 and 64, yet they have fewer health problems than those 65 and above. In addition, the situation of older persons above 65 requires greater policy consideration as they have increasing health challenges that are not all catered for under the NHIS. According to the GSS (2013), and also in line with global statistics, the female elderly population is larger than that of their male counterparts (56% to 44%, respectively). Yet in the policies analyzed, gender difference is not captured. For the purposes of strengthening the various intervention programs aimed at the aged, such as the LEAP and NHIS, there is a need for data on implementation, monitoring, and evaluation.
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