Coverage of non-receipt of cash transfer (Livelihood Empowerment Against Poverty) and associated factors among older persons in the Mampong Municipality, Ghana – a quantitative analysis

Social assistance in the form of a cash transfer (CT) or in-kind has been recognised as a social protection strategy in tackling poverty and providing financial protection for individuals and households. Though social protection was missing under the Millennium Development Goals (MDGs), it was recognised as a tool for alleviating poverty under the Sustainable Development Goals (SDGs). Social protection is influential in achieving a wider range of development goals such as health, social inclusion and poverty reduction [1]. It is estimated that at least 45.0% of the world’s population benefits from one social protection programme or the other. As of 2015, about 71.0% of the world’s population had not received the full range of benefits stemming from child and family benefits to old-age pensions [2]. The origin of social protection interventions is attributed to the western world where its role in meeting the MDGs has been well documented in countries such as the United States, Britain and Germany [3]. In developing countries, social protection has gradually found its place on the developmental agenda, and the African continent is not excluded from the rise and institutionalisation of social protection across the various continents in the world. According to the African Union (AU), social protection is defined as “a “package“ of policies and programmes with the aim of reducing poverty and vulnerability of large segments of the population” [4]. Social protection policies include cash transfers. Despite the gradual increase and extent of social protection programmes across continents, only a small portion of these interventions address the needs of older persons [3].

Globally, cash transfers as a form of social protection over the last few years have received attention as a poverty reduction strategy in many countries [5]. Cash transfers provide money to low-income families and households to help alleviate poverty and increase food consumption among such populations [6]. The Progresa progress programme in Mexico, Latin America was the first cash transfer programme to be designed and implemented. It was introduced as a national conditional cash transfer (CCT) program to reduce extreme poverty in Mexico. Currently, it is one of the most extensive CCT programs in the world [7]. Countries such as Brazil, Bolivia and South African have also implemented cash transfer programmes as key strategies to tackle poverty [8]. Cash transfer programmes, whether conditional (where recipients are expected to meet certain conditionalities) or unconditional (usually to persons such as older persons) have a positive impact on school attendance among children [9], reduction in HIV incidence among adolescents [10], uptake of nutrition interventions [11], children’s health improvements [1], and increased in household food consumption [6]. In Kenya, household food security is an immediate benefit of (conditional) cash transfers [12]. Among older persons, there is evidence of marked improvement in their dwelling characteristics and acquired household assets [13]. Old age is associated with age-related ill-health and disability, and in Ghana, elderly recipients of cash transfers utilized health services such as eye surgery and the required medication [14, 15]. Cash transfers have also been found to improve the social empowerment status, access to health services and economic security of persons with disabilities [16, 17].

Population ageing, which is the shift in the age structure of the world’s population towards the older age group affects both the developed and developing countries [18]. The reduction in fertility and mortality rates, rise in life expectancy, improvements in health technology, and advances in economic and industrial technology have resulted in population ageing [19]. Worldwide, it is estimated that a total of 1.5 billion older persons (over 60 years old) will be added to the world’s population by 2050 [20]. Eighty percent of older persons will be found in low and middle income countries (LMICs) [15, 21]. In Africa, the increase in the population of older persons coupled with the changing pattern in the care for older persons in the traditional family system may affect the social, cultural and support for older persons. Consequently, a cash transfer programme is crucial for older persons and the absence of cash transfers for older persons may have negative implications on their well-being. Urbanisation and the disintegration of family structures accompanied by the high cost of meeting quality and appropriate health care services predispose older populations to diseases and ill-health challenges [22]. Poverty affects older persons adversely. The risk of poverty among the elderly is significant relative to younger adult persons [23]. Older populations often fall into the poorest population groups in most developing countries. This has been attributed to the inequalities they experienced early in life [24]. According to the International Labour Organisation (ILO), older persons continue to depend on family support arrangements [2]. Non-contributory pensions such as cash transfers have been implemented in developing countries to reduce poverty in old age [25]. This intervention is not only crucial into meeting the needs of older persons, but it also helps in achieving the Sustainable Development Goals to reduce all forms of poverty (Goal 1), ensure healthy lives and the promotion of well-being (Goal 3), and achieve gender equality (Goal 5) [24].

There are diverse actors implementing cash transfer programmes for the elderly ranging from the traditional social institutions to state actors, Non-Governmental Organisations (NGOs), international NGOs (INGOs) and bilateral donors [5]. The impact of cash transfers begins with the recipient, and then expands to the household, wider community, and eventually the country [26]. However, some studies have pointed out errors of inclusion and exclusion in targeting recipients for cash transfers [27‐30]. For instance, in most cases, older adults who are not poor are included while excluding poor prime-aged adults [27]. In the context of these arguments, this paper explores the coverage of non-participation in the cash grant programme (Livelihood Empowerment Against Poverty (LEAP)), and the associated factors among older persons (65+ years) in the Mampong Municipality, Ashanti region. This study provides the first quantitative analysis of the coverage of non-receipt, and associated factors with the LEAP programme in LEAP-targeted communities in the Ashanti region of Ghana. In doing so, this paper contributes to the limited body of evidence on non-receipt of cash transfers among older persons in the Ghanaian context.

Evidence relating to factors associated with older persons’ non-receipt of cash transfers is scarce. Most studies focused their analysis on only beneficiaries, hence, missing out on the extent of coverage and the associated factors concerning non-participation in cash transfers among older persons [30, 35‐37]. Much of the earlier work concentrated on the importance and impacts of these transfer programmes on old age and ageing in developing countries [25, 26, 37‐42]. Though there have been studies on older persons’ participation in cash transfers in Ghana [36, 41, 42], there is limited available data on the coverage of non-receipt of cash transfer and the associated factors among older persons in LEAP-targeted communities in Ghana. This study seeks to address these identified gaps in the literature by making a modest contribution to the extent of non-participation of older persons in cash transfer programmes in the context of Ghana.

The purpose of this study was to explore the coverage of non-participation in the cash grant programme, LEAP, and the associated factors among older persons in the Mampong Municipality in the Ashanti region of Ghana. The study found that majority of older persons residing in LEAP-targeted communities were non-recipients of the cash transfer. Although there is a rise in cash transfers as a form of formal social protection mechanisms in many developing countries [55], and the eroding of extended family support systems in most developing countries [56, 57], majority of older persons are non-recipients of the cash grant. The coverage gap in cash transfer has been found to exist among older persons, and this has been attributed to implementation or take-up problems [58]. Interestingly, the National Social Protection Policy reported that there is inadequate coverage of cash transfer, LEAP, which provides social assistance to older persons [23]. There is evidence that the contribution of cash transfer as social protection to the survival and livelihood of beneficiaries, especially older persons are enormous [59‐61]. In most sub-Saharan African (SSA) countries, there is low coverage of contributed-based pension schemes [62]. Cash transfer programmes such as LEAP serve as a stop-gap in fighting poverty for older persons. Nevertheless, there is evidence that targeting older persons in cash transfers compared to other target populations such as children and women of child-bearing age [8, 63, 64] is inadequate [64].

It was observed that marital status positively affected non-receipt of cash transfer, especially those who were in marital unions. Unmarried older persons were more likely to be recipients of cash transfers relative to those who were married. This was consistent in two of the models. Marriage is regarded as social status, a responsibility, trust and achievement [48]. About two-thirds of the study respondents were not married. This could be due to being widowed, divorced or never married. Often, many older persons are typically widowed [19]. Some form of social protection and social capital and network could be derived from marriage for older persons through spousal and relation support [19]. There is evidence that older persons who are not married are potentially associated with food insecurity [65‐68], and this has implications for poverty. Hence, the need for cash transfers.

The findings from this study highlight the importance of location in cash transfer participation in Ghana. This effect did not vary across the five models. The analysis showed that older persons are more likely to reside in rural areas than in urban centres. This finding is supported by earlier studies [19, 69]. Findings from this study showed that about half of the participants had no occupation. Those who are employed are engaged in small scale agriculture where access to income and social security are often limited. Many of them have or had suffered from one form of non-communicable diseases such as stroke, hypertension and diabetes. The country’s adult hypertension prevalence ranges from 19.0 to 48.0% [70, 71], and the analysis showed that most participants have or have had one form of non-communicable diseases such as stroke, hypertension and diabetes. Hypertension prevalence was higher in urban areas compared to rural localities [72]. In poor urban communities, females were found to be more hypertensive than males [73]. From nationally representative data on older adults ≥50 years in Ghana, the author found rural residents to be twice as likely as those in urban areas to have a chronic non-communicable condition. However, there was no variation by sex [71]. The prevalence of diabetes and stroke among older adults ≥50 years in Ghana is 7.0 and 4.9% respectively [71]. Hence, given the criteria for participating in LEAP being 65 years and older without productive capacity may have contributed to this rural-urban differentials. Having urban older persons less likely to be cash grant recipients have implications for heightening intra urban inequalities. In contrast, studies have reported that urban dwellers especially workers in regular wage employment benefit from social protection such as social assistance as compared to the rural majority than those in informal urban settlements in developing countries [74]. The need to further explore this variation in urban slums dwellers, particularly, among older persons is not only crucial for human existence but policy reforms. Contrarily, other studies have asserted that fending for one’s self was one of the challenges among rural older persons in Ghana, attributing it to the lack of pension schemes for older persons [75].

Education also negatively affected the non-receipt of LEAP. Having attained primary education consistently increased the effect of being a cash transfer recipient in four models. Further analysis of the results showed some level of association between education level attained and the presence of the primary caregiver in the same household. Participants with no formal education were more likely to reside in separate households with their primary caregiver. The presence of a primary caregiver was associated with participating in cash transfers in this study. Furthermore, in Ghana, the main selection process for LEAP has been through household using the proxy means test [31]. This methodology has been reported to be associated with a very small proportion of potential beneficiaries [30, 76]. Nonetheless, a correlation between social cash transfer programmes and education among beneficiaries in developing countries like Malawi has also been reported [30]. The authors reported that beneficiaries tend to have very little or no formal education [30]. In a qualitative study in the region of the study area, poverty and multiple deprivations were found to be associated with old age [77]. The author further attributed this to the low levels of education among older persons [77]. Hence, cash transfers ensure access to basic needs such as food, health and decent livelihoods.

Previous studies show that the growing complexity of the living arrangement of children of older persons will result in weaker family ties. This will lessen their support for ageing parents [15]. This study revealed that about a third of the respondents live alone and one-fifth have no primary caregiver. Although a substantial proportion lives alone, earlier studies had found lower proportions [78, 79]. But, caregiving (informal) is common in most developing countries, including Ghana [80]. Those without a primary caregiver were more likely to be non-recipients of the cash transfers by six folds relative to those with a caregiver in separate households. This implies that the presence of a primary caregiver has a positive influence on participating in cash grant programmes. It has been reported in the United States that caregivers (informal carers) often act as mediators in ensuring older persons access social services such as health [81], for which cash grant programmes are not exempted. In the effort to improve the coverage of cash transfers among older persons, there is a need for policymakers and implementers to build a bridge between carers and the success of grant programmes.

The study further observed that informal social protection such as family or informal caregiving complements formal social protection like cash transfers. Some older persons depend on the assistance of non-state actors such as the family system. In the effort to improve the overall quality of life for older persons, there is a need for policymakers and practitioners to strengthen the relationship between formal and informal social protection programmes. This may be boosted through community engagements, incorporating local leadership in the care for older persons devoid of political interference, intensification of education and sensitisation on old age, the ageing process and the associated challenges.

Studies on social pensions particularly for older persons have cited age (60 or 65 years and above), poverty, disability and unemployment as the selection criteria in most developing countries including Ghana [23, 82, 83, 84]. Exploring evidence from Ghana’s LEAP programme in the Nadowli-Kaleo district in the Upper West region using a qualitative exploratory research design, the authors found that more women compared to men receive LEAP benefits [42]. This was attributed to poverty being pronounced among women than men especially in Africa, where women suffer from restrictions in choices and opportunities relative to men [41]. Also, in rural Malawi, beneficiaries were found to be women and persons with very little or no formal education [30]. However, this study found no association between factors like age, sex, occupation, and household wealth index, and non-receipt of cash transfers among older persons. Findings from this study, therefore, could be attributed to the targeting methodology that measures household-level characteristics but not that of older persons such as the nature of remittances and levels of ill-health [30, 76]. Other studies have also underscored the existing political and institutional-related weaknesses characterising the exclusion and inclusion errors in older persons’ receipt in cash grant programmes [40, 85]. For instance, older persons with direct connections to local government officials are more likely to be beneficiaries compared to poor older persons without these connections [40].

While this study quantitatively investigated the coverage of non-receipt of cash transfers, further research is required regarding perceptions, experiences and impact on wellbeing, especially in the study setting. Most participants were found to be non-recipients of the cash grant. This study recommends the need for a non-contributory universal old-age pension scheme compared to the target setting cash transfer programme for older persons. Furthermore, the study investigated the associated factors at the microsystem such as intrapersonal and household levels. The study findings underscore the relevance of demographic, socio-economic and living arrangements for non-receipt of cash transfer in Ghana, particularly in the study setting. Lifestyle risk factors and health-related factors had no effects on non-receipt of cash transfers. This indicates that households with older persons adequately participate in the cash transfer programme especially, in rural localities. This emphasises on the significance of individual and household factors for Ghana’s cash grant programme. This calls for the consideration of individual characteristics of older persons in targeting programmes such as cash grants taking into account the inequalities that exist within households. Currently, the commonly used eligibility criteria in participating in the cash grant programme focus on household-level characteristics resulting in non-receipt among older persons. Hence, further studies evaluating the performance of Ghana’ cash transfer programme targeting older persons at the individual level is in line with the country’s revised 2010 National Ageing Policy calling for the need to strengthen social protection schemes for older persons. This will not only support dignified ageing among older persons, but it will also ensure they have full economic and social participation in society. This study also provides the platform for further research regarding the macro-system exploring the various actors such as community, institutional and at the national policy level involvements in the provision of cash transfers particularly for older persons in Ghana.