Informing evidence-based policies for ageing and health in Ghana

Abstract Problem Ghana’s population is ageing. In 2011, the Government of Ghana requested technical support from the World Health Organization (WHO) to help revise national policies on ageing and health. Approach We applied WHO’s knowledge translation framework on ageing and health to assist evidence based policy-making in Ghana. First, we defined priority problems and health system responses by performing a country assessment of epidemiologic data, policy review, site visits and interviews of key informants. Second, we gathered evidence on effective health systems interventions in low- middle- and high-income countries. Third, key stakeholders were engaged in a policy dialogue. Fourth, policy briefs were developed and presented to the Ghana Health Services. Local setting Ghana has a well-structured health system that can adapt to meet the health care needs of older people. Relevant changes Six problems were selected as priorities, however after the policy dialogue, only five were agreed as priorities by the stakeholders. The key stakeholders drafted evidence-based policy recommendations that were used to develop policy briefs. The briefs were presented to the Ghana Health Service in 2014. Lessons learnt The framework can be used to build local capacity on evidence-informed policy-making. However, knowledge translation tools need further development to be used in low-income countries and in the field of ageing. The terms and language of the tools need to be adapted to local contexts. Evidence for health system interventions on ageing populations is very limited, particularly for low- and middle-income settings.


Introduction
Population ageing presents challenges and opportunities and requires action on the part of national policy-makers. 1 However, in low-and middle-income countries, which often have high rates of maternal mortality and infectious diseases, effective responses to the health needs of older people need to be prioritized. In addition, evidence on health systems interventions for the ageing population and evidence-based responses are often not available or applied in these countries. 2,3 To bridge the gap between evidence and policy in the field of ageing, the World Health Organization (WHO) with the support of Age UK, produced a knowledge translation framework on ageing and health in 2012. 3 This framework is based on the SUPPORT tools for evidence-informed health policy-making 4 and the EVIPNet methods designed to support the development of policies based on existing research. 5 In 2012, the Government of Ghana requested technical support to help revise and improve its existing policy and implementation plan on ageing and health. This provided an opportunity to trial the framework in a middle-income country. This paper describes the process used and the main lessons learnt.

Approach
We defined priority health problems by assessing the needs of older people and the national health system and policy context. We did an initial informal assessment of the political environment and found that the use of knowledge translation in the country was favourable with a national ageing policy released in July 2010 6 and an implementation plan in place. There was also good local epidemiological data on older people's needs from the Study on global ageing and adult health, which includes a nationally-representative sample of 3923 Ghanaians older than 50 years. 7 Ghana has a well-structured health system that could be extended to meet the health care needs of older people, although expertise in ageing is scarce. In 2010, 6.7% of the population in Ghana were older than 60 years (6.0% men; 7.3% women) and the proportion of older people is increasing. The country is undergoing an epidemiological transition with the emergence of noncommunicable diseases as the major cause of disease burden in this age group.
Using epidemiologic evidence, review of policy documents, site visits and interviews with key informants, we first drafted a country assessment report that identified priority problems. Second, we synthetized evidence on effective health system interventions for each identified problem. Information was obtained from the WHO package of essential noncommunicable diseases interventions for primary health care in low-resource settings 8 and from the McMaster Health Forum's health systems evidence database. 9 Time and resource constraints limited our searches to only one global database. The McMaster database is the most comprehensive, 9 free access source to evidence on how to strengthen health systems. It contains AMSTAR (A Measurement Tool to Assess Systematic Reviews)-graded systematic reviews of research about ageing interventions in low-middle-and high-income countries.
Third, the Ghana Health Service, with WHO support, organized a three-day policy dialogue to discuss the identi-

Results
Using the country assessment report, we identified six priority problems, based on prevalence, impact on health, amenability to change within the country context and alignment with the 2010 Ghana National Ageing Policy: (i) undiagnosed and untreated hypertension; (ii) high prevalence of respiratory problems; (iii) limitation of physical function affecting social participation and quality of life; (iv) poor utilization of health-care services by older people; (v) inadequate preparedness of the health workforce to care for older people; and (vi) obesity.
Participants in the policy dialogue replaced obesity with visual and hearing impairment. While the latter did not emerge as a priority from the available epidemiologic data, these conditions are common elsewhere. Studies from Ghana suggest that approximately 8.0% of outpatients reported hearing issues, 10 and experts believe that the proportion of people with visual impairment is high.
Similarly, while dementia was not identified as a priority problem, participants felt it should be specified within the limitation of physical function priority. This is because there is a low awareness of the problem and there are limited services for people with dementia.
When participants were divided into working groups, there was no interest in the respiratory diseases problem. Consequently, this problem was not addressed. The exclusion of respiratory problems from the agenda does not mean they are not a prevalent and important health concern for the people in Ghana, but that the context did not support a policy response to this problem at this time.
The groups developed a more nuanced understanding of the problems and reframed some of them. For example, the problem of undiagnosed and untreated hypertension was reframed as high prevalence and low control of hypertension, since the problem was not simply under-diagnosis, but also inadequate long-term treatment. The Study on global ageing and adult health showed that 57% of people older than 50 years in Ghana had hypertension on clinical examination. However, only 23% of them were aware of their condition and of these people, 4.1% were on longterm treatment. 7 This highlights the gap between awareness and control as well as the need for better adherence to treatment. 11,12 Participants suggested that inadequate ongoing treatment may be due to low health insurance coverage in older Ghanaians, even though insurance is free for people older than 70 years. The Study on global ageing and adult health confirmed that insurance coverage is below 50% for people older than 60 years. Other participants discussed the difficulty of conveying the concept of chronic conditions and the need for ongoing treatment within the older people's belief systems. Understanding of chronic disease and curability varies for different population groups in Ghana, with complex relationships between knowledge, beliefs and health practices. 13 Consequently, the problem of hypertension was reframed from limited access to screening and drug treatments, to an issue concerning older people's understanding of the nature of chronic disease and chronic care.
The working group's final definition of the five priority problems were (i) undiagnosed and untreated hypertension; (ii) functional impairment and social isolation; (iii) poor utilization of healthcare services by older people; (iv) inadequate preparedness of the health workforce to care for older people; and (v) high level of sensory impairment (visual impairment and hearing loss) which are undetected and/or unmanaged among the elderly.
As a next step, the groups considered policy options and interventions using evidence on cost-effective health systems responses to ageing. Direct evidence for such responses in middle-income countries is limited and generalization from higher income settings may not be appropriate. Another challenge arose from how the priorities were selected, since the selection process was mainly based on epidemiologic studies and not a health systems approach. Participants therefore restructured the meeting to allow further discussion on how to build health systems that would address the selected priorities and the health system weakness. This led to a list of key interventions (Box 1) to be included in policy briefs. The policy

Box 1. Recommended interventions for ageing and health in Ghana
• Sensitize the community to the health needs of older adults; targeting information and education efforts to the public, carers, community leaders and religious organizations. • Integrate ageing and health in the community health workers' programme. • Build workforce capacity at all levels in the health system. • Create age-friendly health facilities. • Broaden insurance coverage by increasing the range of services and the number of people who are eligible. • Make devices for hearing and visual impairment available to people in need.
• Create and empower support groups to assist with screening, education, management and care of older people in communities.
Lessons from the field Policy-making for ageing in Ghana Islene Araujo de Carvalho et al.
briefs recommended relevant health systems responses.
The policy briefs were presented at the strategic planning retreat of the Ghana Health Service in August 2013 and key policy recommendations on ageing were incorporated into its fiveyear operational plan.

Discussion
This is the first use-case of WHO's knowledge translation framework for ageing and health. Our experience shows that the framework can be useful in a middle-income setting to guide the development of evidence-informed policy. The process engaged a wide range of stakeholders and provided a systematic and transparent approach to the appraisal, evaluation and use of evidence in decision-making. It was timed to inform the operational plan of the Ghana Health Service.
However, several challenges arose in the knowledge translation process. While the policy dialogue was well-attended, engagement of key stakeholders was difficult due to competing demands on their time. Most participants were not experienced in using research findings and could not relate to the terms used in the SUP-PORT tools and EVIPNet methods. We therefore revised the tools during the meeting to include more familiar language, to enable participants to stay engaged in the knowledge translation process. Finally, the lack of evidence on health systems interventions for middle-income settings resulted in the use of more anecdotal evidence to inform the policy briefs.
In conclusion (Box 2), this project suggests that a knowledge translation approach to develop a policy on ageing and health can be useful in middle-income settings. However, the framework needs to be adapted to local settings and more health systems research in low-and middle-income countries is needed. ■

Documentar las políticas basadas en datos empíricos en materia de envejecimiento y salud en Ghana
Situación La población de Ghana está envejeciendo. En 2011, el Gobierno de Ghana solicitó la asistencia técnica de la Organización Mundial de la Salud (OMS) para ayudar a revisar las políticas nacionales sobre el envejecimiento y la salud. Enfoque Aplicamos el marco de traducción de conocimientos de la OMS sobre el envejecimiento y la salud para apoyar la formulación de políticas basadas en datos empíricos en Ghana. En primer lugar, definimos los problemas prioritarios y las respuestas del sistema de salud mediante la realización de una evaluación nacional de los datos epidemiológicos, una revisión de la política, visitas de campo y entrevistas a informantes clave. En segundo lugar, recopilamos datos empíricos sobre las intervenciones de los sistemas de salud eficaces en países de ingresos bajos, medios y altos. En tercer lugar, las principales partes interesadas entablaron un diálogo sobre políticas y, en cuarto Lessons from the field Policy-making for ageing in Ghana Islene Araujo de Carvalho et al.