Evidence from the Kagera Region Tanzania
Older people – the last in the queue
Von Stefan Hofmann
In 1978 Alma-Ata set a vision and an imperative to the world leaders to reach out for everybody with primary health care. 40 years later statistics confirm impressively how much has been achieved even if a lot still needs to be done. How does this translate in one corner of the world and with one particular group of people? The example of Kwa Wazee which was founded fifteen years ago in Tanzania’s Kagera Region brings evidence from the field.
In about eighty self organised neighbourhood-groups older people regularly meet to practise simple forms of health protection. Under the guidance of their peer health assistants they do body exercices to strenghten the back and the joints or are instructed in low cost forms of preventative health. Photo: Stefan Hofmann, Kwa Wazee
Carine Weiss: Kwa Wazee describes its programme as a learning laboratory and is one of only few organisations with a clear focus on older people. How would you describe the main health issues of older people when you started fifteen years ago?
Stefan Hofmann: When Kwa Wazee was set up early in the new Millennium in Kagera – one of the epicenters of HIV/AIDS – the Declaration of Alma-Ata appeared as a mere piece of paper: The pandemic had thrown almost the whole population into an acute crisis and most severely hit its weakest members. Older people clearly were amongst these weakest, yet their most precarious situation was largely ignored until their role as carers for orphaned grandchildren could no longer be overlooked.
In 2003 Kwa Wazee started to support older people with very modest but regular and predictable cash transfers – pensions and child support for those older people who were carers. Strong and multi-layered impacts could be observed very soon. A comparison study after a few years confirmed that a pension of roughly 5 US Dollars a month led to highly significant improvements in most areas of livelihood, nutrition and psycho-social wellbeing.
However the study also revealed that over 65% of all older people declared themselves as often or always sick in the last 12 months and dozens of interviews showed that older people were systematically excluded from health care - not only because of long walking distances or unaffordable transport costs. In group discussions, older people mentioned severe bureaucratic barriers, refusals of being treated or even verbal abuse by health care providers at health centers. Not one of them could report to have benefitted from those health services which the Government had announced to be free of charge for the elderly. As an older person you were obviously the last in the queue.
Every year on Octobre 1st, the 'International Day of Older Persons‘ thousands of elderly people assemble in one of the villages of the District. The parade, the speeches, the presentations of song and dance from every part of the District are testimony to the vitality of the oldest generation and to their determination to campaign for a future with more security and better access to quality health services. Photo: Stefan Hofmann, Kwa Wazee
Not just recipients of care but actors in health
Carine Weiss: With the obvious lack of primary health care by the government for old people, where did Kwa Wazee detect the biggest needs or deficits and how did it focus its own health approach?
Stefan Hofmann: One of the first lessons we learnt was that social protection was the single biggest element to a healthier life for vulnerable older people. Campaigning for a national pension scheme consequently had to be a priority. But in the absence of adequate primary health care, needs and deficits were obvious even for those who benefitted from a pension. With little sign that the health system would adapt in foreseeable time and with very little funds available Kwa Wazee and the older people themselves were challenged to find new approaches.
Health prevention and mutual support
The paydays for the pension offered the opportunity to facilitate the formation of mutual support groups which soon became very popular. They represented an ideal structure to promote grassroot health care. These groups could ensure some basic protection for members who got sick. Services range from sharing company and bringing food to collecting water or firewood and contributing to hospital costs from the group savings. Quite remarkably many groups started to open up their groups for older people who could not receive a pension.
As part of preventive care two members of each group were trained by Kwa Wazee as ‘health assistants’ to bring elements of basic health care into their groups. This included the knowledge of risk factors and prevention measures, but also regular physical exercises to keep up the mobility and to strengthen the joints and the muscles. Pains in joints and back pains had been identified as most frequent health issues among the elderly.
A committee member adresses part of an older people’s council. Since 2011 councils have been set up in each of over forty Wards of the District. Each of them has it’s own chart and agenda how to promote the rights, better protection and social inclusion of older people. Photo: Stefan Hofmann, Kwa Wazee
Access to health facilities
Problems with the eye-sight were among the most frequently observed health problems for older people. According to surveys of Kwa Wazee conducted in different areas in 2013 and 2017 over fifty percent of women and men over 70 years suffered from poor eyesight. If left untreated it will have a strong impact on their capacity to secure their livelihoods and of course also their social inclusion. As a response Kwa Wazee facilitated and financed eye treatment by a mobile eye clinic, which visited even the most remote villages of the District regularly.
Advocate the rights
Kwa Wazee has intensified advocacy of health issues with key stakeholders at Ward and at District level. The active promotion of Older People’s Councils in every Ward gradually brought the older people in a position to claim their rights for quality primary health care, which they did with increasing vigour and legitimacy. This resulted in regular assemblies of hundreds of older people with key actors at all ends of the District and with periodic meetings of delegates at the health centres.
This coincided with an overall more favourable climate for improvements in the health policy for older people and it contributed to changes: Prominent signs in the health centres today state “please give priority to older people” and confirm the services which are cost-exempted. A majority of older people express during the meetings that they had received medication or check-ups free of charge.
The number of health facilities, ambulances or home care nurses has increased – although still far from the targets which were set.
Essentially all elements of protection and care, which have been described, are also part of a holistic approach to strengthen the human capital of older people and their capabilities – physically, psychologically, socially and economically.
Bar talk between Stefan Hofmann and Kate Molesworth at the MMS Symposium 2018. Foto: Christoph Engeli / MMS
Carine Weiss: If you look at the next 12 years before we reach the Agenda 2030 what needs to be done to better reach older people?
Stefan Hofmann: As explained, improvements in primary health care for older people are considerable compared to the early days of Kwa Wazee, yet many barriers and many gaps persist if ‘no one shall be left behind’.
The local team identified transport to the health stations and the few hospitals in the District (which is about 60% of area of Canton of Bern) as one of the biggest challenges. From remote areas without public transport older people have to pay between 15-25’000 TZS (6.5 – 11 USD) to hire a bike-taxi to the hospital (a monthly pension to compare with is 15’000 TZS).
In the last decade hospitals observe a gradual shift away from infectious diseases to non-communicable diseases. The growing number of older people and their longer lives will strongly reinforce this trend. However, the present health system is not yet prepared to cope. Medicines for non-communicable diseases are not cost-exempted and according to the team, there is little or no awareness in the population about risk factors or preventive measures.
A survey among 180 people of 70 years of age and older in two villages showed much lower numbers of non-communicable diseases (diagnosed or assumed) than what we expected – It seems because the majority hadn’t seen a doctor.
A lot has been said about special insurance programmes and community-based initiatives like the Community Health Fund. However, none of these institutions in the District has yet found the trust, that an insurance program would effectively protect against unaffordable health costs.
During an Older People’s Council in February 2018, 84% of all older people of Mayondwe Ward set up their own grassroot insurance scheme and agreed to contribute every month with 500 TZS (0.22 USD). This fund supports those who have to go to hospital or are sick at home for a longer period of time Within a few months over 500’000 TSH (220 USD) were collected so that the scheme could start.
The message may well be that instead of waiting for things to happen older people are very well capable to become actors of their own health.
Remarkable Survey results
In 2017 Kwa Wazee carried out a survey with a total of 183 participants aged 70 years or older who were part of a pilot-programme of universal pensions.
When asked about their state of health in the preceding 3 months, 31% of all older people described themselves as sick most of the time; 16% felt often sick, while 4% reported to have no health problems at all. 59% reported to suffer from pains in their joints, 46% from back pains and 51% indicated problems with eyesight. These symptoms were followed by headache, toothache and stomach pains.
19% suffered from Malaria and 19% suffered from high blood pressure which were clinically approved by most of the respondents. 7% of the respondents were diagnosed with ‘weak bones’, 2% with a heart problem and but no one was diagnosed with a depression or dementia.
Stefan Hofmann is part of the founder team of Kwa Wazee. Since 2004 he has been a board member and the executive of Kwa Wazee Switzerland, which is also member of the HelpAge International Network. He has initiated and participated in various studies on older people, mainly based on the evidence from the Kwa Wazee programmes. Teacher and organisational developer by training, Stefan Hofmann has been involved in the setup and the management of various development or socio-cultural projects throughout his professional life. Email