Social Protection – key to healthy ageing. A casestudy from rural Tanzania
Salt and Soap for a life with more security and inclusion
Von Stefan Hofmann
"Without our pension we would be dead for a long time", could often be heard in the first years of the Kwa Wazee Pension Programme and in many cases it didn't seem to be exaggerated: At the beginning of the new millenium it became increasingly visible how severely the HIV/AIDS crisis had affected the entire family system – including the oldest. The vital role of grandparents as carers for orphaned and vulnerable children initiated the focus on older people in general and exposed their particular vulnerabilities. It was revealed how little was known about the ways of living of older people, about their achievements and their potentials. The programmes to support them turned into a permanent journey of discoveries.
17th May 2016. The highest ranked representatives of the Muleba District Government meet assemblies of older people in three different villages. At this occasion they are also confronted with piles of receipts for health services for which older people should actually be exempted. (Photo: Edmund Revelian / Kwa Wazee)
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Protection against severe poverty
Kwa Wazee ('for older people') was founded in 2003 with the objective to support vulnerable older people and older carers with regular payments of cash. The approach was uncommon and unpopular at the time, the amount was small – 4US$ at the start –, the number of beneficiaries was low, but the positive impact was so distinctive and immediate that the programme was gradually scaled up in the following years. The majority of participants were women – half of them main carers for grandchildren.
A study from 2008 on the impact of pensions (Salt, soap and shoes for school, pdf) confirmed the first impressions. In the quantitative part it revealed that older people supported by a pension fared significantly better than a control group in most areas which were investigated, in particular: quantity and variety of the nutrition, provision with basic products, resilience against crises, psychological wellbeing.
A return to more security and inclusion
In the qualitative part of the study older people were asked about the biggest changes since they received a pension. Most frequently could be heard that they were now able to buy salt and soap. The two items turned out to have a metaphoric meaning. Salt not only stood for more food security and for tastier food but also for being back in the social process of giving and receiving: Salt is something you share with your neighbours if they have run out of it. – Soap on the other hand didn't only mean better hygiene and cleanliness, but also improved social inclusion, more self esteem and self confidence.
Pension Day in Nshamba. Once every month older people meet at the paypoints to collect their pensions. The amount of 14'000 TZS is not even 7 Euro, but nonetheless substantial: For many pensioners it is 50 percent or more of all the cash they can spend in a month. (Photo: Christoph Gödan / Kwa Wazee)
Older people – the last in the queue for health services
Despite improved nutrition, improved hygiene and a better psychological wellbeing, a clear improvement of the health as an impact of the pension could not be observed. Although older people who received a pension described themselves as healthier, two thirds of them also declared themselves as often sick or most of the time sick - not much different from those who did not get a pension. Expenses for health remained low.
Access to health facilities was particularly critical: Despite a national policy of exemption of costs for older people, none of all interviewed persons stated during the study of 2008 to have received free treatment. However there were plenty of examples, where services had been refused. You could often hear fatalistic statements like: "If I get sick, the only thing I can do is to go to bed and to hope, it stops somehow."
Prevention, mutual care and self defense
As a consequence of these lessons learned Kwa Wazee started to develop a low cost health programme based on the following elements:
- Mutual support through neighbourhood groups. Kwa Wazee facilitates the formation of support groups among the older people of a neighbourhood. The groups autonomously define their activities which range from support to their members in case of sickness to group savings, to group investments or income generating activities. The groups have subsequently proved to be an ideal structure for activities of preventive health care or for security and advocacy issues. Originally formed by Kwa Wazee 'pensioners', most of the groups have welcomed other older people as well.
- Preventive health care. Members of every mutual support group are trained as health assistants to introduce and to practise simple physical exercises in their group. The assistants also promote basic prevention measures like the use of moskito nets or the purification of drinking water. Occasionally the groups are visited by the health specialist in the Kwa Wazee team for new inputs and refresher trainings.
Gymnastics. A health assistant practises simple body exercises with the rest of her neighbourgroup. The training strengthens the muscles and joints and improves the mobility (Photo: Katja Bush / Kwa Wazee)
- Self defense and self protection. Subsequent to a series of attacks on older women Kwa Wazee introduced workshops in self defense which quickly became popular. Participants learn to create a safer environment and they learn that they are not helpless against possible attacks. The regular practice of simple techniques of self defense has welcome side effects: The mobility of the older people is advanced, they are energized and their self confidence is strenghtened.
- Adocacy for the rights of older people in the health system. Access to health facilities. Although improvements have been made in recent years, adequate treatment of older people in hospitals and dispensaries remains an issue. The facilitation of older people's councils, manifestations on Older People's Day and regular visits of health facilities by delegations of older people also aim to establish the rights of older people. On a concrete level the cooperation with a mobile eye clinic provides access to eye treatment for older people in most remote villages. Improved eye sight is a decisive factor for older people to maintain their autonomy and subsistance.
- Relief from health costs. Private or public insurance systems - like the Community Health Fund - have not sufficiently delivered yet in the area, at least not for older people. Kwa Wazee supports solidarity efforts in the neighbourhood groups by reimbursing part of their health costs. The costs for eye treatment in connection with the mobile eye clinic are also covered.
A Kwa Wazee team member guides a patient after her cataract operation. Operations have a very good success rate if also after care is ensured. (Photo: Kwa Wazee)
This leads to some observations or conclusions
- According to the latest census (2012) 3.8% of the population in Muleba District are 65 years or older. For most of them sickness represents an increased poverty risk. Along with expenses for treatment or medication older people in rural areas face considerable expenses for transport and often suffer reductions or loss of their subsistance income. A minimal social protection offered by a pension constitutes the first and most important element of a health policy.
- While communicable diseases like HIV/AIDS or Malaria are slightly in retreat, chronic or non communicable diseases become increasingly visible. Ten years ago high blood pressure, diabetes, cancer or forms of dementia were hardly ever mentioned by older people. Mostly because these diseases were neither diagnosed nor treated. To find an adequate response to non communicable diseases of a growing older population will be one of the challenges for a national health system.
- In the last couple of years improvements can be observed in low cost or free treatment of older people in state health facilities. This is also due to the fact that older people are better organised – for example in older people's councils. They increasingly see themselves as part of a civil society which is ready to express its needs and to claim its rights.
- The risk of older people to be exposed to extreme poverty has slightly decreased, statistically and also visibly in the villages throughout the District. HIV/AIDS is still an important factor, the consequences however have become less comprehensive. The number of vulnerable children where the grandparents have to step in as main carers for example has decreased. Older people's perspectives to get some support from their families has improved following an above average economic growth in the last few years.
- Zanzibar, semi-autonomous part of Tanzania has introduced universal pensions from the age of 70 years in April 2016. It is hoped that this move will precipate efforts to introduce social pensions in Tanzania and in the neighbouring countries.
15th November 2015; The first older people in Mainland Tanzania to collect a universal pension. The District Executive hands out a pension in Ikondo village as part of a new pilot scheme by Kwa Wazee. (Photo: Edmund Revelian / Kwa Wazee
Pilot with a vision
Because funds were very limited from the beginning, Kwa Wazee was forced to make a selection of beneficiaries. With proxy criteria and the recommendation of village committees or older people's groups Kwa Wazee tried to identifie those older people who needed it most. However it was one of the lessons learned that in an environment where the biggest part of the population suffers from poverty a selection can never be sufficiently fair. In addition to this every selection also means marginalization and positions a minimal social protection of older people as a priviledge instead of a right. It's encouraging to see that in the national debate about the introduction of social pensions, a universal approach is clearly favoured.
This November Kwa Wazee has started a pilot programme in two villages, where all older people from the age of 70 years receive a pension. The pilot, which is planned in coordination with District Authorites aims to provide evidence and lessons learned on all sorts of practical aspects which are related to a universal approach of pension payments. A particular interest lays in village committees – elected by the older people themselves – who will implement the programme. The pilot will be monitored by a baseline survey with all older beneficiaries of the programme. This will also allow to deepen the knowledge on older people in various areas where very little is known so far.
Kwa Wazee was initiated in 2003 and built up in the following years by Dr Kurt Madoerin, a renowned development expert who also co-founded the Regional Psycho Social Support Initiative (REPSSI). The registered Tanzanian NGO Kwa Wazee is run by an experienced local team. Kwa Wazee Switzerland has assisted the programme since the beginning with funding and support in research and programme work. 2016 around 1'100 older people are recipients of a pension by Kwa Wazee. Those among them who are main carers for grandchildren receive child benefits on top of their pension. The cash transfers are complemented by programmes to strengthen the self help activities, the health and the security and the rights of older people. Additional programmes focus on the support and the strengthening of children and adolescents.
Summary of the study: Salt, soap and shoes for school (2008): http://www.kwawazee.ch/application/files/5314/4302/8866/kwa_wazee_evaluation_report.pdf
Stefan Hofmann is founding member and executive of Kwa Wazee Switzerland. He has been coordinator and co-author of various studies on the programme work of Kwa Wazee. Email