Enrolment of older people in social health protection programs in West Africa--does social exclusion play a part?

Although the population of older people in Africa is increasing, and older people are becoming increasingly vulnerable due to urbanisation, breakdown of family structures and rising healthcare costs, most African countries have no social health protection for older people. Two exceptions include Senegal's Plan Sesame, a user fees exemption for older people and Ghana's National Health Insurance Scheme (NHIS) where older people are exempt from paying premiums. Evidence on whether older people are aware of and enrolling in these schemes is however lacking. We aim to fill this gap. Besides exploring economic indicators, we also investigate whether social exclusion determines enrolment of older people. This is the first study that tries to explore the social, political, economic and cultural (SPEC) dimensions of social exclusion in the context of social health protection programs for older people. Data were collected by two cross-sectional household surveys conducted in Ghana and Senegal in 2012. We develop SPEC indices and conduct logistic regressions to study the determinants of enrolment. Our results indicate that older people vulnerable to social exclusion in all SPEC dimensions are less likely to enrol in Plan Sesame and those that are vulnerable in the political dimension are less likely to enrol in NHIS. Efforts should be taken to specifically enrol older people in rural areas, ethnic minorities, women and those isolated due to a lack of social support. Consideration should also be paid to modify scheme features such as eliminating the registration fee for older people in NHIS and creating administration offices for ID cards in remote communities in Senegal.