Introduction

An increase in the ageing population is a reality in many sub-Saharan African (SSA) countries. Older people in SSA are defined as those aged 60 years and above [1]. Sub-Saharan Africa, consisting of 48 of the 54 African countries and excluding northern African countries, was home to an estimated 46 million people aged 60 years and above in 2015 [1, 2]. This number is projected to increase more than twofold by 2050, indicating that the region will have the fastest growth rate of older people compared to any other region of the world within this period [2, 3]. Sub-Saharan Africa is, however, the most impoverished region of the world with most of the countries classified as low-income countries [4].

In realization of the ageing problem, members of the United Nations and the African Union, as well as many governments in SSA, signed the two international frameworks on ageing, the 2002 United Nations Madrid International Plan of Action on Ageing (MIPAA) and the 2003 African Union Policy Framework and Plan of Action on Ageing (AU-Plan). These two international frameworks emphasized three strategies: (1) multidimensional health promotion to prevent disease and disability among the older people; (2) implementation of policies to ensure unrestricted access to adequate rehabilitation and curative care for the older people who already suffer from chronic diseases and disability; and (3) adequate training of the healthcare workforce for the care of older people [5, 6]. In order to achieve these goals, the AU including SSA governments proposed two actions for implementation in the African Union Health Strategy 2007–2013 document. The action plans are: (1) To incorporate preventive and curative care services for major NCDs in primary health care; and (2) to improve access to health care for the older people by removing financial barriers and creating provisions for the social protection of older people [7].

However, a decade after the agreements little is known about the progress in the implementation of these policy frameworks in SSA. This review aims to map the policies with regards to the ageing population in SSA since the 2002 MIPAA and the 2003 AU-Plan.

Methods

This scoping review adopted the five-step methodology for scoping reviews propounded by Arskey and O’Malley [8]. The guide proposed by Levac et al. was used in operationalizing each step [9].

Results

Figure 1 describes the flowchart of the selection process for the included articles. A total of 336 reports were found after an electronic database search. An additional 27 reports were identified through manual search. Only 5.0% (18/363) articles were considered potentially relevant for the full-text review and 4.7% (17/363) articles that met the eligibility criteria were included in the final review after the synthesis of information in the papers.

Table 1 presents the general characteristics of the included articles. The majority (10/17; 58.8%) of the articles were policy papers, published within a decade of the MIPAA and AU-Plan agreement. The details of the included articles are presented in supplement 1.

Table 2 presents the list of countries implementing policy for the ageing population in SSA. More than 8 countries in SSA have legislations and are implementing ageing policies while others such as Nigeria, Cameroon and Rwanda have drafted policies.

Discussion

This review showed that countries in SSA, including Ghana, Mozambique, South Africa, Uganda and Tanzania, have ratified national policies on the ageing population, while a few like Nigeria, Cameroon and Rwanda have drafted policies which are awaiting passage into law by their legislatures [10, 11, 12, 13, 14]. This observation is consistent with the United Nations Economic Commission for Africa report on the implementation of the MIPAA in Africa [15], and an improvement over a previous report [16]. This, no doubt, is commendable. However, it appears most of the governments lack the political will to implement these policies, considering the long period between the time of legislation and its implementation (as in the case of Zimbabwe Older Persons Act), and the many impediments to the legislation of drafted policies, as exemplified in the revised National Policy on Ageing (2008) in Nigeria [16, 17]. Even in the countries that have legislated the policies, meager resources are allocated to the implementation [18].

The current policies to promote access to health care for older people in SSA are not encouraging. With the exception of countries such as Senegal, Ghana and South Africa that have either implemented free healthcare or exempted the older people from paying health insurance premiums, the older people in many other SSA countries are not covered by health insurance [19, 20, 21, 22, 23, 24, 25, 26, 27, 28]. Nigeria, the country with the largest population of older people in SSA, has no health care access policies targeted at older persons and the health insurance is intrinsically designed to exclude this category of the population [29]. The observation of this review is in line with the previous reports [17, 30]. The lack or inadequate health insurance coverage for older people will restrict their access to healthcare and thus contributes to preventable deaths among them.

It also appears that only a few countries in SSA, including South Africa, Ghana, Nigeria and Cameroon, have evidence of integration of NCDs treatments into PHC [31, 32, 33]. This observation, which has earlier been documented [30], indicates a lack of preparedness of the national governments in SSA for an imminent disaster. The World Health Organization estimates in 2015 showed an increasing mortality due to NCDs in SSA and indicated that by 2020, NCDs will be the main cause of morbidity and mortality in the region [17, 32]. Already, in many West African countries such as Nigeria and Ghana, NCDs are responsible more for older people’s deaths and admissions to the hospitals than infectious diseases such as tuberculosis and HIV/AIDS [33]. Considering the limited resources available to many governments in SSA, it will be wise to give priority to interventions that aim at preventing and reducing NCDs; this can only be achieved if the NCD management is integrated into PHC.

Mental health appears not to be a health priority in SSA. This review showed that only South Africa and Kenya have incorporated mental health into the national policies on ageing consistent with the WHO reports [16], and even in these two countries, translating the policy into action has received little impetus from the governments and there is evidence that the policy is not achieving the desired goal [34]. Mental health has rarely been integrated into PHC in SSA despite studies that have shown the feasibility and the health benefits of such integration in the region [34, 35, 36]. According to the 2013 Global Burden of Diseases estimates, mental disorders including depression, schizophrenia and anxiety disorders account for almost 10% of the disease burden in SSA, parallel to 14% global disease burden [37]. The morbidity and mortality from NCDs and mental disorders no doubt will take a great toll on the meager health care resources in many SSA countries. The healthcare systems in SSA therefore need to be responsive and adopt a course approach that is built on PHC.

Countries in SSA including Cameroon, Kenya, South Africa and Nigeria have plans in their national ageing policies to promote training in gerontology for health care providers and the development of a cadre of academic geriatricians [10, 11, 13, 17, 31]. The policies also highlighted the establishment and funding of geriatric research institutions, although this has largely not been translated into action, and government support for institutions offering geriatric training is almost non-existent except in countries such as Kenya and South Africa [38]. The number of institutions offering courses in geriatrics and gerontology in SSA is increasing although it is still grossly inadequate. This review showed an improvement in the number of institutions offering geriatric training compared to a previous report [39].

Despite the challenges, researchers in SSA continue to make significant contributions, judging from the number of published articles on geriatrics and gerontology in peer-reviewed journals [40, 41]. However, this achievement is still not adequate to fill the information gap necessary for effective policy formulation and action on healthy ageing in the SSA. Most of the research on ageing in SSA has focused on healthcare accessibility [23, 24, 25, 26], while studies that can convincingly influence government policy are lacking. This review observed that there is a dearth of studies on the reasons for the slow implementation of the ageing policies and the economic and human loss associated with the non-implementation of the policies. Economic data is a major factor that can influence the decision of policy makers especially when setting priorities and making decisions in the face of competing national interests [42].

Limitations

This review did not consider publications in French, which is a major language spoken in some countries in SSA particularly in West Africa. Consequently, national policies and local perceptions of issues affecting healthy ageing in these nations might have been omitted. The review also did not cover articles published in books; thus, the possibility exists that some critical contributions to the discussions could have been missed.

Conclusions

Although progress has been made by SSA in policy formulation on healthy ageing, not much has been achieved with the implementation of these policies. Access to healthcare for older persons in the region remains limited. Many countries in SSA appear to be striving towards the integration of NCDs into PHC but there is generally a low priority for mental health while support for training and research on geriatrics and gerontology is poor. Sub-Saharan Africa needs to prioritize health care of older people in their developmental plans. Training of healthcare personnel on the care of older people should also be given an impetus in the region. A regional collaboration in this regard is advocated.

Additional File

The additional file for this article can be found as follows: