Factors Influencing Access to Reliable Health Care Financing among Elderly Population in Africa

Population is ageing rapidly in all regions of the world and unreliable health care financing is capable of hindering older people from seeking competent medical attention which in turn may lead to their suffering, insecurity and/or death. In Africa, lack of access to reliable health care financing in old age poses serious development challenges and it is detrimental to healthy ageing, especially because elderly population are known to be facing various health challenges which require huge financial costs. Existing studies have shown that it is not sufficient to provide reliable health care financing for older people, it is more important to provide them access to these services. Ensuring that the elderly population has access to reliable health care financing in particular as well as other available and possible social support mechanisms that may encourage the provision of and access to reliable health care financing in general is a challenge and very key to healthy ageing. Through authors’ experiences in the health care system, narrative review of existing literature and interactions with some elderly people, this article explores various factors influencing older people’s access to reliable health care financing. It is believed that understanding of factors influencing access to reliable health care financing among older people in Africa will go a long way in directing policies toward the right course.


Introduction
The whole world is ageing. Ageing population has become the experience of many developed countries and is fast reaching the turn of countries in the developing world [1]. People who were 65 years and above in age represented 5.1 per cent of global population in 1950, 9.0 per cent in 2018, and will be 16.0 per cent in 2050 [1,2]. By that year 2050, 80 per cent of older people (60+ years) globally will be living in low and middle income countries (LMIC) [3]. It is important to note that while this demographic shift is a sign of societal progress which calls for celebration especially for LMIC, it may also pose serious health, security and development challenges if provision of and access to innovative and reliable health care financing mechanisms and strategies are not in view. This is because lack of access to reliable health care financing is capable of hindering older people from seeking competent medical attention to address their inevitable health care needs and challenges, and this in turn may lead to their suffering, insecurity and/or death [4].
In Africa, lack of access to reliable health care financing in old age poses serious development challenges and it is detrimental to healthy ageing, especially because older people are known to be facing various health challenges which require huge financial costs. According to World Health Organisation (2010), reliable health care financing mechanism is an important factor for healthy ageing [5]. Considering the financial and health vulnerability of many older people especially in developing countries of the world, provision of and access to reliable health care financing for this demographic category becomes vitally important and inevitable for healthy ageing [6]. It has been shown that it is not sufficient to provide reliable health care financing for older people, it is more important to provide them access to these services [7,8]. Ensuring that older people have access to reliable health care financing in particular as well as other available and possible social support mechanisms that may encourage the provision of and access to reliable health care financing in general is a challenge and very key to healthy ageing. What are the factors influencing older people's access to reliable health care financing? To answer this question, this article starts by conceptualising key concepts, explains the need for access to reliable health care financing among African elderly, provides statistical overview of access to reliable health care, and discusses various factors influencing access to reliable health care financing. Strategies for providing and accessing reliable health care financing are also discussed before providing summary and conclusion.

Conceptualising access to reliable health care financing: a multi-disciplinary approach
Access to reliable health care financing is conceptualised from multi-disciplinary points of view. Generally, ability to have what it takes to finance health care services without any constraining factor(s) whatsoever is fundamental in conceptualising access to health care financing. Following from this, access to reliable health care financing can mean ability to finance health care services without financial hardship. To be able to finance health care services without resulting in catastrophic or impoverished spending requires that psychological, economic, geographical, political, social, and cultural factors be put into consideration. Psychological point of view describes access to reliable health care financing as when an individual or her financial provider is in her right state of mind to finance health care services without resulting in catastrophic or impoverished spending [9]. Although financial resources may be physically available to finance health care services, it is believed that such resources are not useful if an individual or her representative is not in right state of thinking. From this perspective, a baby or an insane person does not have access to reliable health care financing even if she has all the wealth in this world. Hence, older people or their social support providers are considered to have access to reliable health care financing when they are in their right state of mind.
From economic perspective, access to reliable health care financing is conceptualised as the need for health care financing without financial hardship and the availability of such health care financing mechanism to meet the need. While the former explains the demand for reliable health care financing, the later describes the supply of reliable health care financing [10]. Hence, from economic perspective, an older person is said to gain access to reliable health care financing when the need for it meets its supply; that is, when there are available scarce resources (especially financial resources) to meet the insatiable need for health care services in old age. Again, while it is possible for adequate resources to be available to meet the need for health care financing at a given point in time, distance between health seeker and health care provider may be an important constraint. This calls for geographical conceptualization of access to reliable health care financing.
From geographer's standpoint of view, access to reliable health care financing implies ability of health care seeker to be physically present at the geography (or location, place, et cetera) where health care financing services are required and provided [11]. Although an older person may be psychologically fit to finance health care services and may eventually have the financial resources (possibly in bank or at the health insurance provider) to meet her health care needs and challenges, she still lacks access to reliable health care financing if she is unable to physically collect such financial resources from appropriate quarters to finance her health care services probably due to physical frailty, lack of mobility or road block.
Political conceptualisation of access to reliable health care financing explains the governmental policies and political structures that influence people's access to financial health resources. In every government, there are various health care financing mechanisms or models through which health care services can be financed [12]. The proportion of these models in total health care spending is determined by the political climate of every country. For instance, the proportion of out-of-pocket (OOP) payment in total health care expenditure is higher in developing countries than in developed countries [12]. Also, while health care providers receive payment for health care services more via health insurance in developed countries, the health care providers receive payment for health care services more via OOP in developing countries [13]. Hence, an older person who has psychological, economic, and geographical ability/advantage to finance her health care services may be denied access if such a person is expected to pay via health insurance of which she is not enrolled. Alternatively, an individual who is enrolled for health insurance may be denied access to reliable health care financing if payment from health insurance provider is not available probably as a result of workers' strike due to government inability to meet insurance workers' demands.
From social and cultural point of views, access to reliable health care financing can be conceived as involving the relationship between agency and structure. Here, agency represents individual ability to finance health care services freely and independently with as limited structural constraints as possible. On the other hand, structure entails the broader social, cultural, and structural patterns, arrangement and organisations within which an individual seeks to finance her health care services [10]. From these perspectives, an older person with the ability to finance her health care services without resulting in catastrophic or impoverished spending can be constrained if the prevailing health care system is challenged such as lack of appropriate medical technology or personnel, among many other challenges that may face health care system. Sociologists and Anthropologists have debated on whether primacy should be given to agency or structure in the process of analysing a given social system. For examples, Karl Marx, Émile Durkheim, Bronisław Malinowski, Alfred Radcliffe-Brown, and Max Weber gave priorities to either agency or structure in their social analysis. However, recent sociologists such as Anthony Giddens and Pierre Bourdieu have recognised the vitally importance of both agency and structure in altering a given social system. In his notion of structuration, Giddens (1984) stated that just as an agent can alter prevailing structure, the structure can as well change an agent [14]. Also Bourdieu realised the importance of both agency and structure when he used the concepts of 'habitus' , 'field' , and 'capital' to denotes actors with structured and structuring structure, social space where interaction and activities occur, as well as a symbol for the continual remarking of social order respectively [15]. In other words, Pierre Bourdieu used the concepts to explain an interplay in which the external is internalised, just as the internal becomes externalised [10]. Learning from the works of Giddens and Bourdieu, access to reliable health care financing is conceptualised as depending not only on individual, household and/or agency, but also on broader social, cultural and/or structural factors of a given social system. Implicitly, access to reliable health care financing not only involves internal forces but also external ones [10].
Older people's access to reliable and sustainable health care financing requires that sufficient, uninterrupted and continuing funds are available to meet older people's health care needs without compromising or negotiating future generations' ability to achieve same purpose. An important step to achieving reliable health care financing for the elderly is to ensure that adequate and satisfactory social support is provided, the elderly have free access to funds or financial resources provided by social support system, and that funding increases consistently over the coming years to meet up with the demand of demographic transition. Raising and accessing reliable fund for health care financing of the elderly is the responsibility of household, community, state, and non-state actors of every country. Providing access to reliable health care financing is crucial for any country that aims at addressing the inevitable health care needs and challenges of the elderly.

Need for access to reliable health care financing in old age
Everyone desires to reach old age. Old age is the age when many life threatening diseases come up and these health challenges are costly to treat or manage. However, current financial capability of average elderly person in Africa as indicated in the income distribution of African countries shows that many Africans will not be able to afford medical treatment in old age [16,17]. How can the elderly age gracefully? It is through the provision of and access to reliable (and sustainable) health care financing. There is therefore dire and urgent need for the elderly to access reliable health care financing in order to save the generation of elderly population in Africa. Older people experience a diversity of health states. While some elderly people in Africa are in relatively good physical and mental health, many more others experience considerable disability, and health and care challenges. Existing studies have established that the health of older people determines their productivity and the roles they play in the society, and that the health status and challenges among the elderly varies between and within countries, across sex, residence, ethnicity, and socio-economic status [18]. As a result, while health across the life-course has a significant impact on ageing experience, many older people are unable to adapt to changes in their health and remain independent and productive into very old age.
Common health challenges among older people include arthritis; heart or cardiovascular disease; cancer or malignancy such as lung, liver, and breast cancers; respiratory diseases; Alzheimer's disease; osteoporosis; and diabetes mellitus, among many others [19]. Hence, the need to access reliable health care financing for sustainable health care, management and/or cure. Aside common health challenges, the needs of older people vary and are often categorised into physical, intellectual, emotional and social needs [20]. Some of these health care needs and challenges require reliable health care financing and access to them is crucial for healthy ageing. However, access to reliable health care financing are not equitably distributed among elderly population in Africa. While third agers (healthy older people after retirement and are assumed to be productive through a range of activities, reaching from paid work to volunteering, informal care-giving, do-it-yourself and care for oneself) tend to have more access to reliable health care financing, fourth agers (older people who are unproductive as a result of poor health after their retirement and they represent the traditional stereotype of older people, who can contribute only little, if any, to the development of a state) seem to have less access to reliable health care financing.

Access to reliable health care financing statistics
Globally, universal access to reliable health care financing has not been achieved and the proportion of people who have access to reliable health care financing vary from one country to another. Also, the varied rate of access across countries were unequally distributed and disadvantaged or vulnerable people were most denied access, including older people [17,21]. For example, a study conducted among people aged 50+ years with chronic illness in six middle-income countries showed that access rates were unevenly distributed except in South Africa where primary health care was free for all [17]. Specifically, the study demonstrated that the proportion of older people with access to basic chronic care ranged from 20.6 per cent in Mexico to 47.6 per cent in South Africa. In another study among formal sector workers in Ilorin, Nigeria, it was shown that only 13.5 per cent of the respondents had access to reliable health care financing [21]. This proportion excluded the elderly population because they were no more members of the federal civil servants considering their retirement status and hence, lacked access to reliable health care financing. Ensuring that elderly population are provided with and have access to reliable health care financing is therefore crucial especially as the African society experiences demographic change in favour of older people.
Existing studies have not shown consensus on the factors determining access to reliable health care services among the elderly. While some agree that education, place of work, residence, income, age, number of general practitioners, sex, social network and social participation determine access to health care financing and services, some other scholars disagree to some of these factors. For examples, a study carried out in Ilorin, Nigeria established that respondents who had post-secondary education and who were in the federal civil service were more likely to have access to reliable health care financing [21]. This shows that illiterate older people might be denied access to reliable health care financing even if exempted from health insurance premium and the elderly who are not in federal civil service might not have the opportunity of being enrolled in health insurance scheme, which provides reliable health care financing. Another study conducted among the older Chinese indicated that income group, educational attainment, age-category, marital status, gender, and geographical location influence access to reliable health care financing [7]. Inability to access reliable health care financing is detrimental to population health and especially to vulnerable older people. Recent statistics in Nigeria showed that only very small proportion of the total population in Nigeria had access to reliable health care financing [22]. This is worrisome as it indicates high health inequality. Since pooled resources is the only reliable and sustainable source of health care financing [12], provision of, and access to, pooled resources becomes vitally imperative. It is important to note that differential in access to reliable health care financing and other social resources is influenced by many factors [23], and these are discussed in next section.

Factors influencing access to reliable health care financing in old age
Having conceptualised access to reliable health care financing, demonstrated the need for access to reliable health care financing and shown the statistics of access to reliable health care financing, this section discusses various factors influencing access to reliable health care financing in old age. The discussions in this section are based on authors' experiences in the health care system, narrative review of existing literature and interactions with some elderly people. Specifically, the factors that influence access to reliable health care financing in old age, as discussed in this section and depicted in Figure 1, include age, sex, availability of health insurance, income level, educational attainment, social capital and geographical factor.

Age
Age describes how long one has lived on earth. A person's age is considered a critical factor influencing access to reliable health care financing. While it is possible for many working class age category not to have any challenge accessing reliable health care financing, some retirees may experience more difficulty accessing reliable health care financing. This is because the rate of poverty among older people is more than among other age categories due to the fact that many older people are in their economically inactive phase of life [24]. Since older people are less productive (especially the fourth agers), financial resources for health care financing tend to be affected. In addition, in some African countries, a person's age determines whether one will have social health protection or not. That is, provisions are made for older people in some African countries such as Ghana, Rwanda, and Senegal to be exempted from paying health insurance premium [25,26]. This sort of arrangement increases older people's access to reliable health care financing. Age factor determining health care access was confirmed by a study in Ghana which discovered that enrolment for National Health Insurance Scheme exemption policy in Ghana was higher among the elderly which invariably increases access to  health care among older people [26]. Another study conducted among the middleaged and older Chinese indicated that age-category of the elderly influences their chances of gaining access to reliable health care financing [7]. Therefore, as people aged, special consideration must be made in order to ensure that access to reliable health care financing is not denied.

Sex
Sex defines the biological variances between women and men, and these variances are universal and determined at birth. Access to reliable health care financing is also influenced by a person's biological composition especially in African setting where patriarchy system dominates. In Africa, men often demonstrate hegemony in virtually all spheres of life including economy, family and religion. By virtue of men's hegemonic position, they have more control over financial resources and this in turn affords them the opportunity to have more access to reliable health care financing. According to Mensah (2014), the long-standing patriarchy system on the continent of Africa influences access to health care and medicine in favour of males [10]. In addition, some scholars consider women to be in direr need for access to reliable health care financing than men considering their health care needs as pregnant women, new mothers and widows [7,27].

Availability of health insurance
Health insurance refers to a body that provides reliable health care financing for enrollees and it aims at ensuring equal access to quality health care services without financial hardship. The contribution of (social) health insurance in providing reliable health care financing cannot be overemphasised. This is because health insurance performs various benefits that help countries of the world to have access to reliable health care financing, and invariably move closer to achieving universal health coverage [12]. Generally, there seem to be consensus among global researchers that health insurance increases access to reliable health care financing [7,16,17]. Hence, enrolment in health insurance influences older people's access to reliable health care financing. Importantly, older people who are excluded from health insurance (as the case is in many African countries) are denied access to reliable health care financing. Policies that will ensure that older people are enrolled in health insurance are therefore germane in order to safeguard the health care of the elderly and to ensure that their access to reliable health care financing are enhanced.

Income level
This is an important economic factor that influences access to reliable health care financing. Income level measures the amount or quantity of money or financial resources that an individual receives over a period of time. Individual income level varies and many factors determine a person's income level [16]. When the income level of an individual is high, such an individual has more access to reliable health care financing. That is, there is a direct relationship between income level and access to reliable health care financing. In Africa, the income level of many older people is low due to many factors resulting in low access to reliable health care financing. To help this demographic category of people, engagement in productive activities for those who are still healthy after retirement, compulsory enrolment in health insurance with exemption of premium payment, and strong social support, among many others, may be the alternative means to increase older people's access to reliable health care financing. These alternatives become vitally important because some recent studies confirmed that poverty level or lower income group reduces access to reliable health care financing and health care utilisation [7,10].

Educational attainment
An individual's level of education is another factor that influences reliable health care financing. Operations of modern health care system requires that one has certain level of formal education such as ability to communicate officially. Those who lack knowledge of how modern health care system operate are sometimes deny access to reliable health care financing. For example, many people are excluded from social health insurance because awareness level is low or because they lack the knowledge of how it operates. Those affected are mostly those with low educational attainment. In Africa, most people in the informal sector, which more often correlate with those with lower educational attainment, do not have the privilege of being enrolled in health insurance or have the financial resources that can guarantee financial health protection in old age. According to Zhang et al., less-educated older people have a lower chance of accessing reliable health care financing [7]. Hence, elderly possible hope lies in strong social support via their social network in order to experience healthy ageing.

Social capital
Social capital refers to network of relationships between or among people in a social system who share common interest, norms, values, and/or identity and who continue to engage in social interaction for the effective functioning of the social system. While social capital depends largely on extent of one's social network, social network in turn depends on the level of effective and functional relationship one has established over one's lifetime [8]. Hence, access to reliable health care financing is influenced by the level of relationship one has established in the life course. Older people need social network for effective and efficient health care financing considering their health and financial vulnerability, as well as their inability to engage in full productive activity. This is especially true for majority of older people in African who retired mostly from informal sector and who depend mostly on social capital such as children for their health care financing. Every potential older person is therefore encouraged to start building strong social networks in the life course as that can represent a safety net in old age [28]. Social support from social network can be informational, instrumental, emotional, or interactional. In a study conducted in United State of American (USA), it was found that informational support has a positive impact on health care access disparity among older people [28]. Another study among the elderly in Taiwan demonstrated that social capital in terms of social participation and social network influences access to reliable health care financing which invariably determines access to health care services [8].

Geographical factor
As earlier conceptualised, access to reliable health care financing hinges largely on the ability of health care seeker to be physically available where health care financing services are required and provided. It is important to understand that many older people may have financial wherewithal but may be denied access as a result of their inability to be physically present where they will receive financial health resources or where their health care services will be paid for. Access to reliable health care financing is therefore influenced by geographical factor of where the health seeker is or where the health care services will be financed. In a case study of people living with HIV, 'Mdm. A' was denied access to health care financing and services as a result of prohibitive transportation costs [29]. Also, in a crosssectional study in Sweden, it was found that mobility-related factor was associated with health-related quality of life in old age [11]. The issue of being physically present where health care financing is required and provided is crucial for many older people on the continent of Africa for them to experience healthy ageing because many of them rely on public transport that are either costly or unreliable. Also, many health seekers in Africa are very distant from where they will receive and finance their health care services because reliable health care facilities are often located in cities or urban areas and the ones in rural areas are only for the treatment of mild or minor ailment. Moving from rural areas to urban regions, for instance, poses difficulty for many older people in Africa due to transport mobility challenge [10]. Furthermore, intra-urban, intra-continental, and inter-continental disparities in access to reliable health care facilities and financing are usual in this present global society [10].

Strategies for providing and accessing reliable health care financing
Broadly, to provide and access reliable health care financing, three strategies are cogent: Efficient collection of revenue, reprioritisation of government budgets, and engagement of innovative health care financing strategies especially through social support [5]. Principally, there are four models of revenue collection and these include compulsory prepayments, voluntary prepayments, external aid and out-of-pocket payment (OOP) [12]. Since OOP is an inequitable, unreliable and unsustainable source of health care financing, to provide and access reliable health care financing for the elderly therefore requires that countries pay more attention to other revenue collection mechanisms and provide means of accessing these financial resources. While all countries of the world, both poor and rich, can raise more health funding or diversify their funding sources, the number of countries that have any chance of creating sustainable fund from domestic sources alone is very minimal especially in Africa [5]. Hence, the need for global solidarity in order to ensure that many African countries are not denied access to reliable health care financing. If countries and international agencies were to fulfil their international pledges, external aid in developing countries will greatly increase and the shortfall in fund to provide reliable health care financing especially for the elderly would be virtually eliminated [5].
Given priority to government budgets can also contribute greatly to the provision of and access to reliable health care financing. Government budgets in Africa often give health a somewhat low priority. For instance, very infinitesimal number of African countries could reach the target that was agreed to by their Heads of States in the 2001 Abuja Declaration, to spend 15 per cent of their annual budget on health. Currently, only Madagascar allots above the agreed 15 per cent (15.6 per cent) to health [12,30]. Taken as a group, low-and middle-income countries (LMIC) could raise extra over US$ 15 billion/year for health from local sources by increasing the proportion of health expenditure in total government expenditure to 15 per cent [5]. Many developed countries who are near toward achieving universal health coverage allot considerable share of total government expenditure on health [30]. It is therefore incumbent upon many African countries to follow this path so as to aid the provision of and enhance access to reliable health care financing, although, in the long-run, relying solely on government budget to finance health care services may not be sustainable.
Generally, reliable health care financing can be provided through innovative sources of health care financing as well as innovative governance in managing health resources [31], and can be accessed by putting social, political, economic and cultural factors into consideration. Innovative sources of health care financing refers to committed funding sources for health care services, and these funds come from reserved taxes from health hazardous products such as alcohol, tobacco, sugary and salty foods; contributions from social health insurance or dedicated government budget allocation; taxes on air tickets; diaspora bonds (sold to expatriates); levy on foreign exchange transactions; solidarity levies on a range of products and services such as mobile phone calls; social support from social networks such as spouse, children, siblings, friends, association and community members, among many others [5,31]. The potential to increase social support exists in many countries. If this is well examined and allocated to health, providing and accessing reliable health care financing would be greatly enhanced. On the other hand, innovative governance can be referred to as management of funds for health care services such that health care seekers have access to such funds [31]. These funds may be managed by a statutory body that is independent of government with its own governing body and represented by multi-stakeholders such as community health partnership [12]. Some countries such as Singapore and Hong Kong, among many others, follow this innovative governance and it is helpful in accessing reliable health care financing.

Summary and conclusion
This article has conceptualised key concepts from multi-disciplinary stance, explained the need for access to reliable health care financing, described access to reliable health care financing statistics, discussed various factors influencing reliable health care financing and put forward strategies for providing and accessing reliable health care financing. One vitally important policy goal in modern health care system is equity in access to reliable health care financing. Older people require health care services more frequently and intensely, but lack of access to reliable health care financing in Africa, especially among the vulnerable, poses a challenge. With increasing health care costs especially among elderly population in Africa, providing reliable health care financing and removing possible barriers to accessing it is crucial for healthy ageing.