1. Background
The world is experiencing a growth in the proportion and size of the older adult population
. In 2020, the number of people aged 60 years and older outnumbered children younger than 5 years
. According to WHO data from 2019, global life expectancy increased from 66.8 years in 2000 to 73.4 years in 2019, representing a rise of more than 6 years. By 2030, 1 in 6 people in the world will be aged 60 years or over. According to the WHO estimates for 2022
, the proportion of people over 60 will rise from 1 billion in 2020 to 1.4 billion at this point. The world’s population of people aged 60 years and older is expected to double (from 900 million to 1.8 billion) by 2050; however, two-thirds of this growth will come from low- and middle-income countries
.
Studies show that the Healthy Life Expectancy (HALE) has increased by 8% from 58.3 in 2000 to 63.7 in 2019. This indicator should be a positive reflection of the growth of older adults; however, the increase in healthy life expectancy is due to declining mortality rather than reduced years lived with disability
. Older adults are usually prone to a lot of diseases due to their disposition and are more likely to experience multiple health conditions at the same time. Common conditions found in older age include hearing loss, cataracts, osteoarthritis, back and neck pain, refractive errors, diabetes, hypertension, and sometimes depression and dementia
. An additional feature of ageing is also the rise of multiple complex health states together. These are commonly known as geriatric syndromes. Some of the numerous underlying conditions that commonly lead to geriatric syndromes include frailty, falls, delirium, urine incontinence, and pressure from ulcers
. Older adults due to their conditions are known to have high healthcare use which puts a lot of demand on the healthcare delivery system
| [4] | Awoke, M. A., Negin, J., Moller, J., Farell, P., Yawson, A. E., Biritwum, R. B., & Kowal, P. (2017). Predictors of public and private healthcare utilization and associated health system responsiveness among older adults in Ghana. Global health action, 10(1), 1301723. |
[4]
. Low and middle-income countries undoubtedly face this pressure due to the limited availability of healthcare structures and frail health systems
| [4] | Awoke, M. A., Negin, J., Moller, J., Farell, P., Yawson, A. E., Biritwum, R. B., & Kowal, P. (2017). Predictors of public and private healthcare utilization and associated health system responsiveness among older adults in Ghana. Global health action, 10(1), 1301723. |
[4]
.
A study by Cheng et al
| [5] | Cheng, Y., Goodin, A. J., Pahor, M., Manini, T., & Brown, J. D. (2020). Healthcare utilization and physical functioning in older adults in the United States. Journal of the American Geriatrics Society, 68(2), 266-271. |
[5]
reported on the existing association between physical functioning and healthcare utilization and expenditure. They explained that when older adults are in good health and are physically functional, it reduces the burden and pressure on healthcare and vice versa. The significant increase in healthcare utilization especially in the emergency department, inpatient and outpatient service units, home health, and medical visits in the healthcare facilities at large may be due to the intense health-seeking behaviour of older adults
| [5] | Cheng, Y., Goodin, A. J., Pahor, M., Manini, T., & Brown, J. D. (2020). Healthcare utilization and physical functioning in older adults in the United States. Journal of the American Geriatrics Society, 68(2), 266-271. |
[5]
. The access and utilization of healthcare play a major role in improving the health of older adults
| [6] | Saeed, B. I. I., Yawson, A. E., Nguah, S., Agyei-Baffour, P., Emmanuel, N., & Ayesu, E. (2016). Effect of socio-economic factors in utilization of different healthcare services among older adult men and women in Ghana. BMC Health Services Research, 16(1), 1-9. |
[6]
. According to the 2021 census survey in Ghana reported by the Ghana Statistical Service, 4% of adults in the country are aged 65 years and above. This makes the accessibility to essential packages of health services (EPHS) a critical tool for achieving universal health coverage, especially in low and lower-middle-income countries like Ghana
| [7] | Danforth, K., Ahmad, A. M., Blanchet, K., Khalid, M., Means, A. R., Memirie, S. T.,... & Watkins, D. (2023). Monitoring and evaluating the implementation of essential packages of health services. BMJ global health, 8(Suppl 1), e010726. |
[7]
. How functional a monitoring and evaluation system targeted toward older adults is serves as a guidance and standard for the implementation of health services
| [7] | Danforth, K., Ahmad, A. M., Blanchet, K., Khalid, M., Means, A. R., Memirie, S. T.,... & Watkins, D. (2023). Monitoring and evaluating the implementation of essential packages of health services. BMJ global health, 8(Suppl 1), e010726. |
[7]
.
The frailty in the health system of Ghana negatively affects all aspects of health including monitoring and evaluation systems
| [4] | Awoke, M. A., Negin, J., Moller, J., Farell, P., Yawson, A. E., Biritwum, R. B., & Kowal, P. (2017). Predictors of public and private healthcare utilization and associated health system responsiveness among older adults in Ghana. Global health action, 10(1), 1301723. |
[4]
. In the past two decades, numerous African nations have enacted health sector reforms aimed at improving access, equity, quality, effectiveness, efficiency, and sustainability within their health systems
. Monitoring and evaluation (M&E) of healthcare changes are crucial for determining whether nations have accomplished or are likely to meet their major objectives. They enable governments and development partners to provide feedback, allowing modifications to be implemented if strategies do not appear to be functioning or simply require fine-tuning
. The Ministry of Health has a monitoring and evaluation framework to guide M&E activities in the health sector of Ghana. It looks at the actors, processes, and a two-way feedback channel between actors and stakeholders
. A functional monitoring and evaluation system is a great intervention to assess and monitor the trend of healthcare services utilization by older adults
| [7] | Danforth, K., Ahmad, A. M., Blanchet, K., Khalid, M., Means, A. R., Memirie, S. T.,... & Watkins, D. (2023). Monitoring and evaluating the implementation of essential packages of health services. BMJ global health, 8(Suppl 1), e010726. |
| [4] | Awoke, M. A., Negin, J., Moller, J., Farell, P., Yawson, A. E., Biritwum, R. B., & Kowal, P. (2017). Predictors of public and private healthcare utilization and associated health system responsiveness among older adults in Ghana. Global health action, 10(1), 1301723. |
[7, 4]
.
Monitoring and evaluation is an important component of the healthcare system and an intervention for assessing healthcare utilisation, especially for older adults
| [4] | Awoke, M. A., Negin, J., Moller, J., Farell, P., Yawson, A. E., Biritwum, R. B., & Kowal, P. (2017). Predictors of public and private healthcare utilization and associated health system responsiveness among older adults in Ghana. Global health action, 10(1), 1301723. |
[4]
, yet there are inadequate practices and standards in healthcare for low and middle-income countries including Ghana
| [7] | Danforth, K., Ahmad, A. M., Blanchet, K., Khalid, M., Means, A. R., Memirie, S. T.,... & Watkins, D. (2023). Monitoring and evaluating the implementation of essential packages of health services. BMJ global health, 8(Suppl 1), e010726. |
[7]
. There are also no studies conducted in Ghana that review monitoring and evaluation strategies targeted for healthcare utilisation among older adults in Ghana. This study seeks to review published literature and evidence on monitoring and evaluation strategies targeted toward healthcare utilisation among older adults in Ghana. Specifically, the study sought to a) examine monitoring and evaluation strategies of relevant studies looking at the healthcare utilisation interventions targeted at older adults, and b) analyse and generate a comprehensive overview of the Monitoring and Evaluation strategies on healthcare utilisation among older adults. The integrative review sought to assess all literature and policy documents on the study topic across communities of practice and provide a balanced representation of their knowledge and practices.
Monitoring and evaluation framework of the health sector.
There is an M&E framework by the Ministry of Health
to guide monitoring and evaluation activities in the health sector of Ghana. The main objective of the M&E framework is to facilitate evidence-based decision-making and accountability in the health sector through a functional and well-coordinated system
. The objectives of the M and E framework are to define stakeholder roles and responsibilities accurately as well as provide at least one detailed, unbiased yardstick for evaluating health sector performance
. The success of the framework is structured upon five pillars: Stakeholder collaboration and accountability (WHO?), Timely, reliable, and accurate data (HOW?), Comprehensive data repositories (WHAT?), Timely analysis and use of information (ANALYSIS) and Feedback, supportive monitoring and supervision (REACTION AND FEEDBACK).
Figure 1. Relationship between Pillar 1-5.
Pillar 1: Stakeholder collaboration and accountability
Health determinants extend beyond the health sector, requiring collaboration with the corporate sector and other ministries, departments, and organisations
. Sector plans and policies shape operational plans, and stakeholder contributions are essential for performance evaluation. Clear accountability relationships among stakeholders are crucial for effective performance management
. Stakeholders are recognised in areas such as policy formulation and implementation, resource mobilisation, regulation, and health service delivery. Key stakeholders include development partners, NGOs, other ministries, departments, agencies, the private sector, legislature, media, and the public, with roles and obligations outlined under the Common Management Arrangement (CMA)
.
Pillar 2: Timely, reliable, and accurate data
Ensuring the validity of conclusions and actions derived from M&E findings requires timely, accurate, and trustworthy data. All levels of data should be received by MOH within the established timeframes from all reporting entities. In the process of gathering and validating data, it is crucial to reduce errors
.
Pillar 3: Comprehensive data repositories
To comprehensively assess sector performance, data from multiple stakeholders (public, private, and multi-sector) must be captured in existing data systems. This repository should include all necessary data for generating indicators for management decisions, research, and performance monitoring
. The M&E framework relies on routine data, periodic health surveys like the Multi-indicator Cluster Survey and Demographic Health Survey (DHS), in-depth reviews, and research from various stakeholders
. It includes two sets of indicators: a comprehensive set (agency-specific and selected stakeholder indicators) and a sector-wide set (a negotiated subset of the comprehensive set). These indicators provide a balanced measure of the Health Sector Medium Term Plan's implementation and guide information collection for planned activities
.
Pillar 4: Timely analysis and use of information
The sector's ability to respond efficiently to performance deviations depends on its capacity to promptly analyse and apply data. The M&E framework identifies three levels of data analysis: operational, managerial, and strategic. Operational analysis involves ongoing evaluation of agency or stakeholder performance, allowing for the identification of deviations and corrective measures, with data being agency or stakeholder-specific. Managerial analysis assesses the efficiency and effectiveness of plan implementation. Strategic analysis focuses on access, quality, and equity in strategic policy
.
Pillar 5: Feedback, supportive monitoring and supervision
Pillar 1 emphasises stakeholder participation and accountability through a reciprocal feedback approach, where feedback is given in both directions constructively to inspire, resolve discrepancies, and ensure better performance
. For holistic assessment, annual and half-yearly reviews, reports on the ministry's website, in-depth review reports, and all framework information should be shared with key stakeholders and the public
.
2. Methodology
2.1. Study Area
Ghana’s Ministry of Health (MOH) oversees public health services, healthcare management, and medical education
| [10] | Alhassan, R. K. (2017). Healthcare quality in Ghana: Improving healthcare quality and health worker motivation to promote sustainable health insurance. |
[10]
. Following ACT 525, the Ghana Health Service and Teaching Hospitals now handle promotion, preventive, curative, and rehabilitative care, while the MOH focuses on policy, monitoring, resource mobilisation, and regulation
.
The healthcare system includes five provider levels: CHPS compounds, health centres and clinics, district hospitals, regional hospitals, and tertiary hospitals. CHPS compounds offer basic preventive and curative services at the community level
| [12] | Adusei, A. B., Bour, H., Amu, H., & Afriyie, A. (2024). Community-based Health Planning and Services programme in Ghana: a systematic review. Frontiers in Public Health, 12, 1337803. |
[12]
. Health centres provide both preventive and curative care, along with outreach services
| [10] | Alhassan, R. K. (2017). Healthcare quality in Ghana: Improving healthcare quality and health worker motivation to promote sustainable health insurance. |
[10]
. District hospitals, often mission-based, deliver curative services, supported by the District Health Administration (DHA)
| [10] | Alhassan, R. K. (2017). Healthcare quality in Ghana: Improving healthcare quality and health worker motivation to promote sustainable health insurance. |
[10]
. Regional hospitals provide curative services, with public health services managed by the District Health Management Team (DHMT) and the Regional Health Administration (RHA)
| [10] | Alhassan, R. K. (2017). Healthcare quality in Ghana: Improving healthcare quality and health worker motivation to promote sustainable health insurance. |
[10]
. The private sector, which contributes 35% of health services, mainly offers curative care with limited preventive services
.
2.2. Study Design
The study used the integrative review method proposed by Whittemore and Knafl
, which synthesises research literature across various methodologies through a five-stage process: problem identification, literature search, data evaluation, data analysis, and presentation of findings. This approach is unique in its methodological strategies, enhancing the rigour of the process. It is particularly valuable in evidence-based practice as it integrates both experimental and non-experimental research.
2.2.1. Problem Identification
Monitoring and evaluation are critical stages in every intervention, initiative, or plan. However, studies report that most countries have severely limited or absent M & E culture. This constraint can also be found in healthcare usage methods for geriatrics or older persons
| [4] | Awoke, M. A., Negin, J., Moller, J., Farell, P., Yawson, A. E., Biritwum, R. B., & Kowal, P. (2017). Predictors of public and private healthcare utilization and associated health system responsiveness among older adults in Ghana. Global health action, 10(1), 1301723. |
| [7] | Danforth, K., Ahmad, A. M., Blanchet, K., Khalid, M., Means, A. R., Memirie, S. T.,... & Watkins, D. (2023). Monitoring and evaluating the implementation of essential packages of health services. BMJ global health, 8(Suppl 1), e010726. |
[4, 7]
. Our study highlights the M & E techniques and treatments used throughout the years to improve healthcare usage in older individuals and provides a detailed analysis of them.
2.2.2. Literature Search
The literature search for the study was conducted using Scopus, PubMed, Google Scholar, and Google Search, involving title screening, abstract screening, and full-text screening, which resulted in 7 papers for the integrative review. Initially, 17,963 papers were found, reduced to 300 after removing duplicates. Title screening narrowed it down to 17 papers, abstract screening to 10, and full-text screening finalised seven papers. The inclusion criteria were research materials on M&E strategies, healthcare access, and utilisation for older adults (aged 60+), empirical studies, reviews, theoretical articles, policy papers, reports, and studies published within the last 15 years. The exclusion criteria were anecdotal or opinion-based articles without empirical or theoretical backing, studies published over 20 years ago unless foundational, and articles not originating from Ghana. The flow chart in
Figure 3 gives a summary of the literature search.
Figure 2. Flow chart of Selected Study Procedure.
2.2.3. Data Evaluation
It is crucial to assess the calibre of sources that serve as outlier representations in an integrative review with a variety of empirical sources. The articles were assessed to see if they fulfilled the study's objectives. Hence, the representativeness, informational value, methodological quality, and validity of the available data are considered.
2.2.4. Data Analysis and Presentation
A cohesive and integrated conclusion regarding the study issue was reached by organising, classifying, and summarising the data that was taken from primary sources.
Table 1 provides a summary of the study characteristics of selected studies. The extracted data from the various sources was transformed into a display that compiles the data from the chosen papers, producing a data display in the form of tables, graphs, and charts. A context analysis was conducted on the M&E strategies identified in the selected papers. The identification of trends in the study topics was included as part of the general discussion.
Table 1. Study Characteristics of Selected Paper.
| TITLE | AUTHOR | YEAR OF PUBLICATION | STUDY DESIGN | SAMPLE SIZE | STUDY POPULATION | STUDY SITE | AIMS AND OBJECTIVES |
1 | Ageing in Ghana | Essuman & Mate-Kole | 2021 | Review | N/A | Older adults | Ghana | To explore ageing in Ghana |
2 | Barriers to health care access and utilisation among aged indigents under the Livelihood Empowerment Against Poverty Programme (LEAP): the perspective of users and service providers in north-western Ghana | [15] | Domapielle, M. K., Dassah, C., Dordaa, F., Cheabu, B. S. N., & Sulemana, M. (2023). Barriers to health care access and utilization among aged indigents under the Livelihood Empowerment Against Poverty Programme (LEAP): the perspective of users and service providers in north-western Ghana. Primary Health Care Research and Development, 24. https://doi.org/10.1017/S1463423623000385 |
[15] | Domapielle et al | 2023 | Case Study | N/A | Older adults | Daffiama-Bussie-Issa District in the Upper West Region of Ghana | To investigate the obstacles to primary health care utilisation and access among elderly impoverished individuals under Ghana's Livelihood Empowerment Against Poverty Programme (LEAP) using the framework for poverty and access to healthcare. |
3 | National Case Study on data, evidence, and information for healthy ageing in Ghana | [16] | Ghana Statistical Service. (2020). Ghana Case Study on Ageing Final. |
[16] | Ghana Statistical Service | 2020 | Case Study | N/A | Older adults | Ghana | To establish links between sectors, support the identification and enhancement of national initiatives to develop and fortify local and subnational data collection systems, and encourage co-production, analysis, and use of data by a broad spectrum of stakeholders, including older adults themselves, with empirical evidence. |
4 | Ghana Country report on the implementation of the Madrid international plan of action on ageing (MIPAA) | [17] | National Population Council. (2007). Ghana Country Report on The Implementation of The Madrid International Plan Of Action On Ageing (MIPAA). |
[17] | National Population Council | 2007 | Report | N/A | Older adults | Ghana | To provide a brief account of the approaches adopted and activities carried out by the various stakeholders, relevant Government and Non-Governmental organizations to implement the Madrid International Plan of Action on Ageing (MIPAA) over the past five years. |
5 | National Ageing Policy 'Ageing with Security' | [18] | Ministry of Employment and Social Welfare. (2010). Government of Ghana National Ageing Policy “Ageing With Security And Dignity” July 2010 Ministry Of Employment And Social Welfare. |
[18] | Ministry of Employment and Social Welfare | 2010 | Policy document | N/A | Older adults | Ghana | In order to facilitate older people's complete participation in the process of national development, it is important to attain their total social, economic, and cultural reintegration into mainstream society. |
6 | National Health Policy: Ensuring health for all | [19] | Ministry of Health. (2020). National Health Policy: Ensuring healthy lives for all Revised Edition Ministry of Health Republic Of Ghana. |
[19] | Ministry of Health | 2020 | Policy document | N/A | Older adults | Ghana | To guarantee that there will be enhanced coordination, complementarity, and synergy across all public sector ministries and other stakeholders in order to accomplish the national health goal. |
7 | Towards universal access to healthcare for older adults: an assessment of the old-age exemption policy under Ghana’s National Health Insurance Scheme | [20] | Dake, F. A. A., & van der Wielen, N. (2020). Towards universal access to healthcare for older adults: An assessment of the old-age exemption policy under Ghana’s National Health Insurance Scheme. International Journal for Equity in Health, 19(1). https://doi.org/10.1186/s12939-020-1156-2 |
[20] | Dake & van der Wielen | 2020 | Ghana Living Standards Survey (GLSS 7) | 1534 | Aged 70 years and older | Ghana | To examine the old age premium exemption policy for older adults under Ghana’s NHIS. |
Figure 3. Flow chart of Selected Study Procedure.
Table 1 presents the various characteristics extracted from the studies selected. The sample population are older adults within the country; however, the studies and policy documents did not provide information on their sample sizes.
Figure 3 presents the analysis of the year of publication.
3. Results
3.1. Conceptual Framework
A conceptual framework was developed based on the findings of the research study. The framework guides the examination of monitoring and evaluation (M&E) strategies for healthcare utilization among older adults in Ghana. This framework integrates key components that collectively influence older adults' healthcare outcomes. It highlights their interconnectivity and guides them in understanding their relationship.The framework is structured upon these componentsPolicy Framework and GuidelinesData Collection SystemsHealthcare Access and Utilisation, d) Effectiveness of M&E StrategiesChallenges and Limitations, and f) Recommendations for Improvement. Monitoring and evaluation for geriatric care assesses data through policy frameworks and guidelines, as well as data collection systems. These systems help to evaluate healthcare access and utilisation for older populations, which directly affect health outcomes like challenges and limitations of M&E structures and the effectiveness of M&E strategies. Healthcare access and utilisation also help to set up recommendations and interventions for the improvement of M&E structures.
Figure 4 shows the conceptual framework of M&E strategies for healthcare utilisation among older adults.
Figure 4. Conceptual framework of M&E strategies for healthcare utilization among older adults.
3.1.1. Policy Framework and Guidelines
This component takes into consideration policy guidelines like the National Ageing Policy and the Ghana Health Service Guidelines. The National Ageing Policy provides the foundation for addressing the healthcare needs of older adults, while the guideline is set to provide standards and protocols for health services. They both have components of M&E strategies for older adults. They provide the foundational structure and direction for data collection systems. National policies and guidelines shape the design and implementation of data collection systems. These policies outline the goals, standards, and protocols that guide how data should be collected, managed, and used. Establishing clear objectives and methods of policies ensures that data collection systems are designed and implemented effectively, enabling consistent and accurate data gathering across the healthcare system.
3.1.2. Data Collection Systems
Data collection systems aid in the access to routine information on older adults. The Ghana Health Service is responsible for District Health Information Management System (DHIMSII). It is their primary system for collecting health data. Besides the DHIMSII, other sources of data like SSNIT and NHIS provide data through their monitoring activities. The Ghana Living Standard Survey (GLSS) also provides socioeconomic and health data relevant to older adults. The effectiveness of data collection systems influences the understanding of healthcare access and utilisation patterns. Effective data collection systems provide comprehensive and accurate data, which can be used to identify trends, gaps, and areas of need in healthcare services. This information is crucial for understanding how older adults access healthcare, the types of services they use, and the frequency of their utilisation.
3.1.3. Healthcare Access and Utilisation
Access to healthcare is highly driven by certain barriers and facilitators. Some factors influencing access to healthcare services for older adults include geographic, economic, and social barriers. Data collection systems help in identifying service utilisation patterns among older adults, which may identify the types and frequency of healthcare services used by older adults. Insights gained from analysing healthcare access and utilisation data are essential for evaluating the effectiveness of M&E strategies. Understanding how older adults use healthcare services, the barriers they face, and the outcomes they experience provides valuable information for assessing whether current M&E strategies are meeting their objectives. This evaluation helps determine the strengths and weaknesses of M&E practices and informs adjustments and improvements. For example, if data reveals that older adults are frequently re-admitted to hospitals due to preventable conditions, this insight can indicate that M&E strategies need to focus more on preventive care and follow-up services.
3.1.4. Effectiveness of M&E Strategies
Data quality, coverage accuracy, and comprehensiveness of health data collected are influenced by policy frameworks and guidelines, data collection systems, and healthcare accessibility and utilisation. The effectiveness of M&E strategies helps in determining how M&E data informs healthcare policies and practices for older adults. The quality of M&E data plays a critical role in shaping healthcare policies and practices. High-quality, reliable data allows policymakers and healthcare providers to make informed decisions, develop effective policies, and implement practices that address the specific needs of older adults. When M&E data accurately reflects healthcare realities, it can lead to meaningful improvements in service delivery and outcomes. Accurate M&E data showing high rates of untreated chronic conditions among older adults can prompt the development of policies aimed at increasing access to chronic disease management programs and resources.
3.1.5. Challenges and Limitations
Data constraints issues related to the quality, completeness, and accessibility of data and challenges with coverage gaps in capturing data on unregistered individuals and underserved populations are some challenges. Identifying the challenges and limitations in the current M&E systems is crucial for developing actionable recommendations for improvement. Understanding the specific issues, such as data gaps, quality constraints, and accessibility problems, allows for targeted strategies to enhance data collection, analysis, and utilisation. These recommendations aim to address the identified challenges and improve the overall effectiveness of healthcare services for older adults. If a significant challenge identified is the lack of data on unregistered older adults, recommendations might include initiatives to increase NHIS registration among older populations or alternative methods to capture health data from this group.
3.1.6. Recommendations for Improvement
Healthcare access and utilisation set up recommendations and interventions for the improvement of M&E structures. The challenges and limitations identified are crucial for formulating actionable recommendations for improvement. Suggested recommendations examine strategies to improve the quality and scope of health data. Recommendations for policy and program enhancements are also made in the study to strengthen healthcare services and policies for older adults.
3.2. Context Analysis Findings
3.2.1. Creation of a Policy Environment
The 1994 revision of Ghana's National Population Policy addresses the needs of older individuals and those with disabilities, advocating for new or reinforced legislation to protect their rights and ensure their full societal participation. It calls for public awareness campaigns to address issues like limited income and unemployment. Article 37(2) (b) of Ghana's 1992 Constitution mandates the State to protect and promote fundamental human rights, including the right of seniors to participate in development. Government strategies for the elderly include the National Social Protection Strategy of 2006, the Ghana National Disability Policy, the Livelihood Empowerment Against Poverty (LEAP) initiative, and the NHIS exemption policy for those aged 70 and older. Additionally, the "National Ageing Policy: Ageing with Security and Dignity" addresses the living conditions, poverty, and healthcare of the elderly.
3.2.2. Ghana Health Service
The Ghana Health Service Council, which is the governing body of the independent Executive Agency, is the vehicle through which the Minister of Health (MoH) exercises authority over the Ghana Health Service (GHS). In Ghana, primary data on all health outcomes, including those of the elderly are compiled by the Ghana Health Service Council. All service delivery points generate essential regular service data on health service consumption, morbidity, and disease patterns. Health managers at all levels can utilise these data to make well-informed decisions, plan, and create budgets. The health sector's monitoring and evaluation system uses routine service data to analyse and disseminate findings. In doing so, it facilitates performance reflection and evaluation and identifies areas of weakness for improving intervention programmes.
3.2.3. DHIMS II
Ghana Health Service and the University of Oslo collaborated to develop the software known as the District Health Information Management System (DHIMSII). DHIMSII provides an all-inclusive HMIS solution for the reporting and analytical needs of district health administrations and healthcare facilities at all levels. It provides a comprehensive HMIS solution based on data warehousing principles and is easily adaptable to the needs of different health systems, such as district, national, regional, and facility health systems, thanks to its modular design. Since the primary source of data is visitors to the medical facility, it excludes those who do not use its services. It is possible that the data does not accurately reflect the whole population. Person-centred information about the health determinants of older adults, including age, gender, diagnosis, cause of death, and other details, can be produced using the DHIMSII data. Based on the total number of visits to healthcare institutions over a specified period, the percentage of older individuals by age can be computed. The GHS gathers basic information about clients and patients, including details about their diagnoses, illnesses, and symptoms. Regardless of whether a client pays out-of-pocket or has insurance, the DHIMSII collects data on every individual who uses services. Additional information about occupation, religion, marital status, and housing location is provided by the patient registrations. There is no formal documentation of the process for using DHIMSII data for programming or interventions targeted at the elderly.
3.2.4. National Health Insurance Authority
A parliamentary act from 2003 created the National Health Insurance Scheme (NHIS) to insulate against the rising costs of essential medical care. Almost 60% of subscribers of the NHIS are exempted from paying an annual premium because it is a significant social intervention program run by the Ghanaian government. Older persons 70 years of age and above who do not contribute to SSNIT as well as SSNIT pensioners are excluded. The NHIA is mandated to register and issue individual membership ID cards to each member to enable members, including the elderly to get medical care. Before issuing ID cards, staff members at the NHIA district offices collect biometric data from individuals. Nevertheless, the NHIA only collects information about those who sign up for the programme. It implies that there is no data on older people who are not registered in the system.
3.2.5. Ghana Living Standard Survey
The World Bank's Policy Research Division launched the Living Standards Measurement Study (LSMS) as a research project in 1980. The project's goal is to provide policymakers with pertinent data on socioeconomic development indicators so they may assess socioeconomic development and examine its causes. Every five to seven years, the Living Standards Survey is conducted. All members of the household are included in the GLSS statistics regarding health. Particulars include time spent, cost, and satisfaction with treatment, as well as whether any members have used health services in the past two weeks and whether they were ill or wounded. The information includes the reasons behind the non-utilisation of healthcare services by those who did. When tracking the health of the senior population, this data is a helpful resource.
3.2.6. Population and Housing Census
The Ghana Statistical Service, which has been conducting the Population and Housing Census (PHC) every ten years since 1960, provides a comprehensive count of Ghana's population. The seven theme categories covered by the census questionnaire are: each person's educational attainment, employment and unemployment, migration, disability status, mortality, housing and its conditions, and each household member's age and sex. Information on older adults can be sourced to promote healthy ageing across the life course.
3.2.7. Social Security and National Insurance Trust
Ghana's National Pension Scheme is administered by the Social Security and National Insurance Trust (SSNIT), a statutory public trust. The Trust stands as the biggest financial institution that is not a bank in the nation. Replacing a portion of lost income due to old age (retirement from active work), infirmity, or death is the main duty of the Scheme. Data is gathered at the time of a pensioner's death to confirm it. The causes of death are recorded and entered into the database as part of the investigations conducted to confirm the death of a scheme participant. These data make it possible to monitor the causes of death among the elderly.
4. Discussion
The population of people who are 60 years and older is expected to reach 2 billion by 2050 due to the increase in life expectancy, the extent to which the world’s population is ageing, and progressing care needs
. The problem created by this demographic transition to the current healthcare systems emphasises the future preparation and access to healthcare for older persons. It is pertinent to examine a range of extended M&E approaches, which can be implemented across the globe with a special focus on sub-Saharan Africa. Monitoring and assessment strategies are paramount in the evaluation of healthcare utilisation among the elderly, ensuring the efficiency and efficacy of healthcare services tailored to their specific requirements
| [4] | Awoke, M. A., Negin, J., Moller, J., Farell, P., Yawson, A. E., Biritwum, R. B., & Kowal, P. (2017). Predictors of public and private healthcare utilization and associated health system responsiveness among older adults in Ghana. Global health action, 10(1), 1301723. |
[4]
. On an international level, many strategies of M&E may be used to monitor healthcare consumption among seniors. One of the essential approaches is the performance of national health surveys by governmental agencies
| [22] | Centers for Disease Control and Prevention. (2023, January 19). National Health Interview Survey (NHIS). Centers for Disease Control and Prevention (.gov). https://www.cdc.gov/nchs/nhis/index.htm |
[22]
. The National Health Interview Survey (NHIS) collects data concerning the health services consumed across the various age groups
| [22] | Centers for Disease Control and Prevention. (2023, January 19). National Health Interview Survey (NHIS). Centers for Disease Control and Prevention (.gov). https://www.cdc.gov/nchs/nhis/index.htm |
[22]
. This data can reveal different and unique aspects of health service utilisation by the elderly. Another powerful instrument for global M&E is the examination of existing healthcare administrative data. This process involves scrutinising the data generated by the various hospital admissions, outpatient attendance, and other related records to understand how older adults are accessing healthcare services
| [23] | Agyemang, C. E., Adjei, S. A., & Addai-Mensah, C. Q. (2017). Predictors of public and private healthcare utilisation and associated health system responsiveness among older adults in Ghana. Global health promotion, 24(1), 42-50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5496095/ |
[23]
. This proves to be much cheaper in comparison to offering nonstop coverage and allows for the detection of possible problems. The employment of electronic health records (EHRs) for the monitoring of healthcare utilization trends over time is also essential since it is a compilation of various information including patient’s personal details, diagnosis, treatment, and healthcare interactions that make it possible for healthcare providers and researchers to look at the trends and patterns in healthcare use by older persons
. Also, population-based surveys such as the National Health and Ageing Trends Study (NHATS) conducted in the US have become important sources of knowledge about health care services consumption among elderly people through collecting data on visits made to hospitals, received health care visits as well as the usage of long-term facilities. These investigations enable one to study differences in health care accessibility and utilisation across different population characteristics
.
Several research methodologies, stakeholder engagement, culturally appropriate approaches, and population-specific objectives aimed at enhancing healthcare accessibility and quality of healthcare have been incorporated in the policies and monitoring and evaluation processes of healthcare utilisation among older adults and other vulnerable populations
| [25] | World Health Organization (2020). Mental Health and Substance Use Programme Rapid Assessment of Service Delivery for Mental, Neurological and Substance Use Disorders during the COVID-19 Pandemic, 2020. |
| [26] | Amoah, P. A., Edusei, J., & Amuzu, D. (2020). Using mobile health to monitor and manage chronic diseases in sub-Saharan Africa: A narrative review of the literature. International Journal of Environmental Research and Public Health, 17(8), 2913. |
[25, 26]
. In addition to these methods, evaluation frames such as the Donabedian model provide a systematic way of examining outcomes from aged individuals’ health services. In this model, there are three main areas through which health service utilisation should be analysed: structure (medical institutions with available resources), process (patient-provider interactions during care provision), and outcome (patient contentment and state of health)
| [28] | Donabedian, A. (1988). The quality of care. How can it be assessed? JAMA, 260(12), 1743-1748. |
[28]
. The model requires the support of multifaceted approaches by multiple healthcare stakeholders such as policymakers, healthcare workers, researchers, and other community structures
| [28] | Donabedian, A. (1988). The quality of care. How can it be assessed? JAMA, 260(12), 1743-1748. |
[28]
. Additionally, the Rapid Assessment of Service Availability (RAISA) developed by the World Health Organisation is an important tool for standardising evaluations of healthcare services. RAISA assesses healthcare accessibility and availability for the elderly, comparing aspects like geriatrics specialists, medications, and health structures accommodating elderly individuals
| [25] | World Health Organization (2020). Mental Health and Substance Use Programme Rapid Assessment of Service Delivery for Mental, Neurological and Substance Use Disorders during the COVID-19 Pandemic, 2020. |
[25]
.
Monitoring and evaluation (M&E) strategies for healthcare usage by elderly people vary across countries, including Sub-Saharan Africa, and often involve diverse data collection methods, appraisal frameworks, and joint efforts tailored to specific regions
| [26] | Amoah, P. A., Edusei, J., & Amuzu, D. (2020). Using mobile health to monitor and manage chronic diseases in sub-Saharan Africa: A narrative review of the literature. International Journal of Environmental Research and Public Health, 17(8), 2913. |
[26]
. In Sub-Saharan Africa, challenges such as resource constraints and dispersed communities necessitate creative M&E approaches, like community-based monitoring and leveraging local health workers and community leaders to capture health facility utilisation data
. Relatives play a significant role in the health-seeking behaviour of older adults, providing valuable insights into the care and challenges faced by the elderly
| [29] | Addae-Mensah, C., Agbleze, A. A., & Awuku, A. Y. (2022). Informal caregivers' experiences and challenges in caring for older adults in Ghana: A scoping review. International Journal of Nursing Studies, 128, 104118. |
[29]
. Innovative methods, such as mHealth technologies, enable real-time data collection on health visits, particularly benefiting elderly individuals in rural areas
| [26] | Amoah, P. A., Edusei, J., & Amuzu, D. (2020). Using mobile health to monitor and manage chronic diseases in sub-Saharan Africa: A narrative review of the literature. International Journal of Environmental Research and Public Health, 17(8), 2913. |
[26]
. In Ghana, M&E practices are tailored to the local context, with data from the National Health Insurance Scheme (NHIS) providing crucial evidence on healthcare access for older adults
| [23] | Agyemang, C. E., Adjei, S. A., & Addai-Mensah, C. Q. (2017). Predictors of public and private healthcare utilisation and associated health system responsiveness among older adults in Ghana. Global health promotion, 24(1), 42-50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5496095/ |
[23]
. Integrating healthcare utilisation data with social protection program information can reveal the impact of these programs on healthcare service use
. Analysing NHIS enrolment and utilisation patterns helps policymakers identify ways to serve the elderly population better
| [23] | Agyemang, C. E., Adjei, S. A., & Addai-Mensah, C. Q. (2017). Predictors of public and private healthcare utilisation and associated health system responsiveness among older adults in Ghana. Global health promotion, 24(1), 42-50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5496095/ |
[23]
.
Partnerships are essential for developing surveillance systems, evaluating and comparing programs, and improving the competencies of care providers and researchers
. In Ghana, the government, NGOs, and academic institutions play a crucial role in implementing monitoring and evaluation plans for elderly healthcare. The Ghana Ageing Study (GAS) assesses the health situation of the elderly, with a focus on healthcare service utilisation through partnerships with various stakeholders
. GAS covers aspects such as treatment during illness and coping with different illnesses, offering policy recommendations for caregivers and policymakers on service delivery for specific demographics
.
Despite the presence of M&E mechanisms, various challenges can hinder the effectiveness of strategies aimed at improving healthcare accessibility and quality for older adults. Moucheraud et al
| [31] | Moucheraud, C., Schwitters, A., Boudreaux, C., Giles, D., Kilmarx, P. H., Ntolo, N.,... & Bangani, Z. (2017). Sustainability of health information systems: a three-country qualitative study in southern Africa. BMC Health Services Research, 17(1), 23. |
[31]
highlighted the inadequate data foundation in low- and middle-income countries, where limited resources result in insufficient human, technical, and financial capacities for comprehensive monitoring and evaluation. This can lead to deficiencies in data collection, analysis, and reporting, thereby limiting the understanding and addressing of healthcare inequalities among older adults. Cultural and practical challenges, such as existing norms, beliefs, language differences, and access barriers, further complicate M&E implementation
. Addressing these issues requires a system-based approach that strengthens data support systems, enhances monitoring and evaluation capabilities, overcomes cultural and organisational barriers, and fosters cooperation among departments, NGOs, universities, and other relevant institutions
| [31] | Moucheraud, C., Schwitters, A., Boudreaux, C., Giles, D., Kilmarx, P. H., Ntolo, N.,... & Bangani, Z. (2017). Sustainability of health information systems: a three-country qualitative study in southern Africa. BMC Health Services Research, 17(1), 23. |
| [3] | WHO, 2019. Global estimate: Life expectancy and healthy life expectancy. Retrieved from https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-life-expectancy-and-healthy-life-expectancy |
[31, 3]
.
4.1. Limitations and Future Directions
The study was limited to assessing M&E strategies for geriatric care utilisation. Future works should look at M&E strategies for health care in Ghana generally, and focus on more indicators besides health care utilisation. The study used an integrated review approach in its synergy, and future studies should look at the usage of systematic review design to ensure the rigour of the study.
4.2. Conclusion
This study effectively identified several monitoring and evaluation (M&E) strategies used in relevant studies that investigated healthcare usage solutions for older persons. The study revealed existing flaws in present legislative frameworks and data collection methodologies by offering a thorough analysis of these M&E initiatives. To strengthen M&E activities, it is critical to make existing data more available and increase data collection for older adults who do not receive formal healthcare. It is also relevant to broaden health insurance coverage and encourage stakeholder collaboration for a more integrated system. These changes will allow for more data-driven decision-making, resulting in better healthcare service delivery and health outcomes for Ghana's ageing population.
,
Helen Bour
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