The Better Health for Older People in Africa Programme aims to improve access to health and care services for 387,763 poor older women, men and their households in four countries- Ethiopia, Tanzania, Mozambique and Zimbabwe. The programme is premised on the principle that the right to health is for people of all ages and hence it is unacceptable that many older people in Africa do not enjoy this right. In its design the programme acknowledges the linkage and interplay between ill health and poverty, recognizing that ill health is both a result of poverty, and a cause of poverty. Therefore, by improving access to health and care services the programme is intended to make older people less vulnerable to both illness and poverty. Through local, national and regional advocacy mostly driven by older people themselves, the programme will also improve accountability by the duty bearers including policy and decision makers as well as service providers.

The expected outcome is that older men and women will have improved access to age-appropriate health and HIV services by the end of the 3-years programme. Towards this outcome, the programme is expected to achieve 5 outputs namely:

1. Training curricula developed and 1,718 health care workers trained on age-appropriate health and HIV services
2. 1,425 Home Based Carers (HBC) are trained and 12,832 older people receive community and home-based care
3. Technical and policy support provided in the four countries for greater access to social protection and health entitlement
4. Older People trained to monitor and advocate locally for access to health, HIV and care services and entitlements
5. HIV and social protection policies and strategies in the four countries and within the region include recommendations made by the programme.

The purpose of the baseline survey was to assess the pre-interventional situation in regard to specific areas of programme focus as represented in the logical framework. The findings of the baseline survey will serve as the base measurement of the key indicators of the programme, against which changes due to programme interventions will be assessed.

The scope of the assessment was limited to the output level of the programmes results framework with the understanding that a follow-up baseline, for the outcome indicators, would be conducted using HelpAge’s Health Outcomes Tool (HOT). Nevertheless, a lot of the findings gathered during this assessment provide useful insights far beyond the planned scope such as examining the contextual premise that informed the design of the programme.

Data was collected from both secondary and primary sources. A combination of approaches, and tools with inbuilt validation mechanisms were used. These included literature review, Focus Group Discussions (FGDs), observation and Key Informant Interviews (KIIs).  The baseline survey employed three main methods for data collection as outlined below:

Desk Review: Desk review was undertaken for all documents pertaining to the program among them; program proposal, draft MEL plan, theory of change, data collection tools and the program log frame. Of most important, the consultants reviewed the program’s impact evaluation plan upon which the benchmarks shall be drawn to monitor the impact of the programme throughout the programme implementation phase.

Key Informant Interviews (KII): Key informant interviews were conducted with persons that are (or will be) most directly involved in the implementation of the program. These persons were carefully selected to ensure inclusion of those with most relevant information. Key Informants included Country Programme Managers, Partner focal persons, district and national ministry of health representatives, Health Records Information Officers (HRIO) at facility level, health facility in-charge, and local administrators, among others.  A total of 29 KIIs were conducted across the four countries

Focus Groups Discussions (FGD): FGDs focused on target program recipients and services providers at the community level; that is older men and women and their household members. This was aimed at identifying among other things: their perception and knowledge on age-appropriate health and HIV services, access to home based care services and general access to healthcare services. Others that were interviewed include Older Citizen Monitoring Groups (OCMGs) and Older People Associations (OPA). A total of 26 FGDs were conducted across the four countries.

Age- friendly and gender sensitive assessment tool: This was conducted at the facility level. This was aimed at ascertaining the extent which targeted health facilities by the program are delivering age-friendly and gender sensitive services to older men and women within their catchment areas. A total of 14 health facilities were assessed across the four countries. The table below represents the number of health facilities that were assessed in each country.

Observation: This was mainly used at the facility level to map-out age-friendly services in the selected facilities; specifically, health facility physical infrastructures.

A mix of both purposive and random sampling methodologies was utilized to arrive at appropriate respondents within the operational areas. Purposive sampling ensured that specific conditions that are important in shaping the findings were considered while random sampling ensured reduced bias on information obtained from the beneficiaries within the purposively targeted areas. Purposive sampling technique was employed to select participants for the KII and FGDs depending on their roles and influence on the program. Health facilities were randomly selected depending on the survey areas at the time.

Quality assurance was maintained at various levels in the survey to ensure the evidence collected meets the standards and expectations within the Terms of Reference for this work.

At the initiation stage of the survey, the consultants met with the Regional Programme Manager and the Regional MEL Adviser to level expectations of the assignment. This in a way also helped the consultants to have a better understanding of the programme and the expected deliverables so as not to compromise the output of the process. The initial desk review also helped the consultants to have a better understanding of the program. The consultants developed the initial draft tools that were shared with HelpAge and partners for feedback and input. This helped to ensure that the proposed questions in the tools were in line with the objectives of the survey and meet expectations. At the field level, mobilization of the group had been conducted in advance by HelpAge. This helped the consultants to meet all the appointments that had been planned hence reducing chances of missing out on important information.

Tanzania has a number of policies that gives a general guide to provision of services and entitlement to older people. These policies include National Health Policy, National Health Sector Strategic Plan 3 (NHSSP -3) currently near ending. The Ministry is in preparation of developing NHSSP 4.  These policies give a general mention of service provision for older people at health centres that; older people should not pay for services; they should be given priority and have a specific area set for them at the health facilities. The government also has NCD and HIV/AIDS strategic plans, but they do not address specific issues affecting older people. Despite the existence of these policies, there is no legislation/law to enforce implementation.

Ethiopia is estimated to have a population of 97.8million, of which 3.8million is estimated to be older people. Over 85% of this population lives mostly in the rural areas where basic services are poor and inaccessible.  The country uses a federal government structure consisting of nine regional states (Afar, Amhara, Oromia, Somali, Benishangul Gumuz, Southern Nations Nationalities and Peoples Region (SNNPR), Gambela, Tigray and Harrari) and two city administrations (Addis Ababa and Dire Dawa). The regional states are then sub-divided into zones and further into Woredas and Kebeles as the smallest unit of administrations. The mandate for health is in the Federal Ministry for Health Ethiopia follows a decentralized health care system, development of the preventive, promotive and curative health care delivery by public, private for profit and not-for profit players in the health sector. The Ethiopian health care delivery which is organized into three tier-system, puts the health extension program, the innovative community-based service delivery (health development army), as a centre of focus for the provision of primary health care services to broad masses.

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