The application of Rawls’ Theory of Justice in providing equitable free Health services to Geriatrics in Tanzania

doi:10.21203/rs.3.rs-4823278/v1

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The application of Rawls’ Theory of Justice in providing equitable free Health services to Geriatrics in Tanzania

https://doi.org/10.21203/rs.3.rs-4823278/v1

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Everyone has the right to a standard of living and adequate for the health and well-being of himself and of his family, including medical care and necessary social services, although health services to elders are compromised. The study aimed to examine application of Rawls Theory of Justice in understanding the institutional arrangements, internal policy and legal framework, the established mechanisms from selected two local government authorities. The study used pragmatism paradigm with concurrent research design and a sample size of 300 respondents were selected through purposive sampling techniques and convenience sampling. A desk based review methods and field data collection approach using questionnaire and interviews was employed to collect data

The study found that there was social welfare committee that deals with social matters though specific responsibilities to geriatrics' health services were not explained. Respondents from 30 interviews revealed that they don't know about free health accessibility to geriatrics. Additionally, the elders' councils are not formed as well as absence of social assistance. Older people are not clearly identified in the villages and there is no proper registration in the village executive offices in recent years and general meetings and poster announcement as mechanisms to sensitization which isn't effective.

The turned carpet of practicing to providing equal political, social and economic opportunities towards participation and services is increasing to different categories of people. The world statistics indicate that people in a given countries are structurally categorical based on children, female, male, youth and older people (geriatric). These groups have different needs to be fulfilled by responsible institutions political, social and economic institutions which timely the countries have been trying to improve. However, among these groups face difficulties which are identified and have been addressed in the country by the given authority so as to improve social services provision. The most group which is seem to be challenged is a group of geriatrics ^[12]. The world theories and practices about societies indicate that the subject of old age and ageing has been of discussing topic to the international community mainly in view of economic, political and social magnitudes. However in most countries the exact definition of elderly age group is controversial that some define it as persons with a chronological age of 65 years and above ^[12]. Geriatrics is mostly suffered from illnesses that require support on access to health services. This multiplies that, health is an important aspect for it is a human right that should be provided equally among members in the society. In addition, equitable health services are achieved as all individuals have opportunity to attain their full potential for health and well-being ^[14].

The United Nations Organisation reports ^[19] show that number of older people in the World has been timely increasing especially in developing nations that are compromising to match with the available resources to cater for older people’s health and nutrition essential for human life. Moreover, the measures and projects are designed to suit the situation of estimated increase of elders to 8 million by 2050 ^[19]. According to Tanzania National census by 2022 shows that one fourth of the population involves geriatrics (URT, 2022). The current world reports indicate that the number of 65 aged people and over was estimated to be 761 million of older people in 2021 and is expected to be 1.6 billion more by 2050 and subsequently to two billions in which affects the provision of health services ^[20].With this increase, governments have been making efforts to set the environment that will respond to the situation. Strong political, economic and social institutions are needed to ensure that every geriatric has equal opportunity to access the right to a standard health service including medical care, the right to security in the event of sickness, old age which are beyond his/her control ^[7]. Health services provision to geriatrics is compromised in many countries which force them to have clear plans and programs to sustain all individuals’ right including access to healthcare by reducing challenges. Additionally, current status reports indicate that geriatrics face healthy difficulties and they are explained to be vulnerable to diseases and states are currently implementing the free health services programme to geriatrics ^[20]. This has been taken as most considerable group due to the fact that, geriatrics loose ability to work and fight against the diseases due to physical control and lower immunity respectively. Scientifically it is proved that geriatrics experience of having chronic diseases, physical disabilities, mental illnesses and other co-morbidities (Saurabh,et Al 2013). All these challenges impair their ability to income generation as they loose energy for economic activities. Elders are subjected to free health due to the fact that elders face challenges to cost sharing and they are incapable of traveling to health facilities ^[17]. This is the fact that, majority of elder people experience poor health as a result of poor life styles and poor nutrition they had during their childhood. Moreover, the prolonged experiences of diseases are a common feature among many older people and health services are not easily accessible to the majority of them besides they are expensive. The functional ability of geriatrics has remained a dependent variable influenced by age, and being reported as people with more difficulties in performing routine activities as age increased, particularly among women (Mwanyangala, et al, 2010). Initiatives are needed as World Health Organisation (WHO, 2022) highlights the four areas of action that should be adhered as stated in the Decade of Healthy Ageing initiative. These include age-friendly environments, free of physical and social barriers; reduced discriminatory ageism and good-quality essential health services as well to providing rehabilitative resources when these become important.

Different programmes including free health services have been designed to save the older people and make them enjoying the rest of their life. Tanzania as among other states declares to have ageing policies adopted through the UN declaration to older people which currently is implemented ^[17]. Tanzania ratified the National Ageing Policy due to the fact that the presences of geriatrics in most of the country have cultural and economic development contributions.

Moreover, the UN declaration describes that there is a need to ensure that environment are conducive to allow older people to access their rights to equitable health services both homes and in all health service facilities. The services to be provided to older people require, clear procedures to identify older people, accessible infrastructure, information and positive attitudes amongst older people as well as the community, local government and stakeholders. Speaking at the climax event in Dodoma on 3rd October 2022 officiated by the former Minister of State, Prime Minister's Office (Policy and Parliamentary Affairs), Hon. George Simbachawene said, “Old age is a source of wisdom and blessings. Elders make us who we are today and who we aspire to be from their lessons through their life experiences” (URT Report, 2022).

Literature set that human being should be free to access social services. It is the role of the government to identify the people in need of free services including health. Tanzania government puts the emphasis to local government authorities that they have a role of identifying geriatrics and exempt them from paying for health services as well as giving them special priority when seeking for treatment ^[17].

Moreover, the government provides directives to ensure that health provision to geriatrics may be effective by identifying and sensitising the elders and community about their responsibilities.

However, the National ageing policy is not well known to community members even geriatrics themselves (Temu et al 2015). The study conducted at Tandale Dispensary, although used a small area, revealed that 33% of 154 respondents were aware about National ageing policy of 2003. However the study concluded that there is still needs to increase more efforts than the current to ensure that geriatrics have equal access to health services per policy implementation.

The government of Tanzania has employed a least one or two Social Welfare Officers in each district council office, and one Social Welfare Officer in some of the regional and district hospitals whose responsibility among other roles is to assess the eligibility of elderly people in accessing free healthcare services ^[18]. Despite the efforts made by the government, there is still a question that not all older people get free health services as it is stated. And there is still complaint from householders that, the services is not free as stated in the policy and most are not beneficiaries with the service. Perhaps, the attitude and knowledge, economic status has left the other without being included. Nevertheless, among other studies one of them concludes that National Ageing Policy is not well implemented as there is a gap between what the policy advocates and its practices on the ground ^[6]. The study was conducted in Morogoro Municipality where the report findings presents that among respondents, 38% of them had low understanding on the concept, process and procedures when it comes to the free health services implementation. On the other hand, 59% of respondents were dissatisfied with the services offered to geriatrics by free health services providers. Moreover, 79% of respondents view that poor implementation of the policy is due to lack of Act and by-laws to support National Ageing Policy on provision of free health services delivery to geriatrics ^[6]. Furthermore the study conducted in Tandale Dispensary in Dar es Salaam City in Tanzania, revealed that 85% of identified geriatrics had never had any free medical services at Tandale and 88% of them were not covered by any health insurance scheme despite the needs as stipulated by national ageing policy ^[16]. Geriatrics should be treated without any form of discrimination, prejudice and stereotypes by ensuring the effective political and social institutions. This will continually help them to maintain or regain the optimum level of physical, mental and emotional well-being and to prevent or delay the onset of illness ^[18]. However, geriatric people face a lot of challenges which threatens their life and access to both social and economic welfare. It needs serious and joint participation of community, local government to ensure this possible. Most of the studies have centered in only health facilities where not all issues about local governments are not covered. Methodologies and theories are not much relevant to explain the involvement of local government to address issues of policy, legal framework, mechanisms in practice. The application of Rawls theory of Justice in health related matters has received little attention to most or all the studies which has been conducted. Therefore, this study rests on examining how local government is involved as a political institution to ensure equitable health services to geriatrics. The application of Rawls Theory of Justice sets to understand the institutional arrangements, internal policy and legal framework, the etablished mechanisms to geriatric identification processes, and how older people and the public in general are sensitized on old age health related problems.

1.1 Theoretical Ground

The study used Rawls Theory of Justice to understand the provision of health services to geratric. The theory was first established by John Rawls 1971 before it undergoes its development and revision of 1999. The theory proposes several assumptions on how the society is needed to be fair and just. His theory of justice as fairness describes a society of free citizens holding equal basic rights and cooperating within an egalitarian economic system. The primary subject of justice according to Rawls is the basic structure of society which exerts a profound influence on individuals' life prospects ^[11].

The theory claims for liberal society (society with equal rights) to have an arrangement of the major political and social institutions, the legal system, the economy, the family, and so on that support justice. Rawls views a society as a basic structure that the local governments, legal system, economic and family should be arranged with a location of justice. These institutions decide the basic human rights and the opportunities to be given to members of the society including right to health services for all. The theory presents two major principles, the greatest equal right of liberty and social and economic inequalities which describes the access of social services.

In the first Principle Rawls highlight that each person has the same indefeasible claim to a fully adequate scheme of equal basic liberties, which scheme is compatible with the same scheme of liberties for all ^[10]. It describes that society is like an institution which its role should to ensure that each person is to have an equal opportunity to the most extensive total system of equal basic liberties that is compatible with a similar system of liberty for all. In this line the first principle asserts that all citizens should have the familiar basic rights and liberties including liberty of conscience and to be treated in accordance with the rule of law, and so on. Geriatrics have a right to access free and equatable health services and health care by responsible institutions including family, community as well as organisations ^[16].

In the second principle, society should be fair and just to ensure that Social and economic inequalities are to be arranged so that they are both under two conditions; first, they are to be attached to offices and positions open to all under conditions of fair equality of opportunity which in most cases elders are not recognised. Secondly, social and economic inequalities are to be arranged to the greatest benefit of the least-advantaged members of society (the difference principle) including geriatrics ^[10].

In line with this theory, the two principles are used to study the concept of liberty and how is used to describe the involvement of the local government as a political institution to fostering the equality in access of health services to Geriatrics. Local governments have should ensure that there are bodies such as helping desk, legal and policy framework to guide families, community members and organisations to support geriatrics.

Moreover, the theory is used to understand the differences people have in access to health services and health care (difference principle) as well as how the opportunities are created to allow accessibility of healthcare to Geriatrics. It is argued that, level of fairness increases as the individuals play their roles in a community or an organisation. Also, the environment should consider the individual differences and the needs each of a member of community needs. On the other hand, the fair and just society provides the equal opportunities to access the available services and resources to every member of the society. However this may be different with what happens in practices. The concept of equity, is not commonly addressed in the society. The opportunities available and its accebility determine that the extent of social and economic inequalities exist in a society ^[10], the second principle.

Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health. Local government authorities as political institutions are emphasized to be just and fair giving equal access to social services to its members including Geriatrics ^[10]. Rawls argues that, the society is a body of resolving the tension between the ideas of freedom and equality. Thus, justice as fairness is constructed that citizens are free and equal and that the society should be fair.

The theory has been centered in politics in general on what is to be accessed in the area by citizens and who is responsible to provide it. These include opportunities to all citizens during decision making about their issues they are concerned. Moreover rights to education, good and equatable health care should be given to all including those who are seriously in needy such like geriatrics. In addition, theory of justice has received little attention amongst researchers to be used in studying other social sciences rather than politics. In line with this theory the study seek to understand how is applied to ensure that institutions are arranged and mechanisms are made to address the health related issues to geriatrics. This includes Mechanisms to information access which is essential to geriatrics. Education (sensitisation) given to them for the understanding of free health provision according to National Ageing policy.

The study used pragmatism paradigm to study the environmental settings for geriatrics to access health services freely among the selected health facilities from Kigoma District Council and Uvinza District council in Kigoma region. The health facilities included Msimba, Simbo, Mahembe, and Kidahwe (Kigoma District Council) and Mwakizega, Sunuka, Kirando, Herembe and Karago (Uvinza District council). The areas are found to be in peripheral to Kigoma town and perceived challenged that represent the other health facilities.

A study employed a concurrent triangulation design to examine the participation of local government in ensuring the provision of equitable health services to geriatrics. Purposive sampling techniques and convenience sampling design was used to select total of 300 participants of this study. Purposive sampling were used to select 30 key informants from officials such as village executive officers, as well as social welfare officials, Doctors, Nurses, District social worker, and WEO/Hamlets who had perceived to have important and useful information for drawing conclusion. On the other hand 270 respondents from community and elders were selected conveniently due to the fact that any individual who met the criteria and willing to participate in a study was selected ^[1]. Additionally, the technique is useful where target population is defined in terms of very broad category. Thus, convenient sampling was used based on different categories including community members with different age groups and gender.

A desk based review methods and field data collection approach was employed to this study to study the provision of health services to geratric people. Both qualitative and quantitative data were collected from secondary data and others from primary data by involving few officials in the selected areas to inform the processes to ensure that Geriatrics have equal opportunities to access free health services. Through the desk based review method researcher was able to collect information from circulars, annual and periodic reports, journals, articles, cases and national statistics reports related to the subject through the libraries. Researcher used both structured and semi-structured interviews were used to gather information from the selected respondents. The interview technique was used to collect the primary data where researcher collected those information at hands. Secondary data were collected from National bureau statistics, annual national reports, current studies and facility reports. Content and thematic analysis methods was used analyse data from open ended questions and SPSS soft ware assisted method was used to analyse quantitative data.

This section provides what was found from the field and secondary data and the rationale of those data with situations.

3.1 Institutional, Policy and Internal Legal framework

The study found that there was social welfare committee who deals with social matters but their job descriptions didn't state about their responsibilities to geriatrics' health accessibilities. Among the 30 interviews revealed that they don't know about free health accessibility to geriatrics. On the other hand the study found that there is no elderly council established to help geriatrics identify the needs including health services. Despite the policy statement ^[16] that there is a need to establish a mechanism (council) that will ensure the availability of older people’s contribution on their affairs(including health services) and those of the community, still the older people claimed that they have never listened such council where they would have gathered to address their challenges and put opinions. This is an indicator that the policy itself isn't supportive to provide desired services due to absence of boards that works in collaboration. In order to ensure the inclusion of older people’s voice in such decisions, older people’s Councils will be established at village/mtaa, ward, district, region and national levels ^[17]. One of the interviewed geriatrics condemned that:-

No specified older people's council to moment which is established, so our affairs are discussed in the family and when we meet in streets or informal gathering. We face lot of challenges to access health services despite the fact that we have been told that health services for us should be free. (Field data, 2023).

Village executive officers recognise that they have a role to form the elders' council although they haven't formed it in all villages. These councils would have saved older people to access health related issues and to provide the difficulties they face.

Yes, I know, yet we haven't formed the older people council due to the fact that roles are not clearly specified. We call them for temporary discussions when we have something to tell them.... (Interview from field data, 2023).

In addition, one of village executive officer, shown to understand the National ageing policy but the implementation was challenging to them. This is in line with the former report which shows that, inadequacy or lack of implementation mechanisms for National Ageing Policy 2003 gave birth to a wide public debate on the unacceptable position regarding elderly social care services in the country. He claimed that, families as social institutions had responsibilities for their elders’ healthcare ^[17].

Families are responsible to take care and ensure that their elders have access to healthcare. We don't have any instruction that even private which we are in collaboration. Only health facilities work with geriatrics once they receive those (Field data, 2023).

In addition, the study found that there are unwritten procedures to protect geriatrics because the formed groups are not active to respond to every challenge. There is no mechanism for report on what is going on in the health facilities. Therefore, no progressive follow-up to those have received the services.

We don't have the elderly council that can give information about current needs of geriatrics.several time we have been receiving of what is going on in health facilities individually. Few reports in office complaining about the service and treatment they have been receiving (Field data, 2023).

This statement denotes the processes are not institutionalised and the provision of health support is provided within families. Majority of the elderly especially in rural areas cannot afford to pay for health services ^[17].

Correspondently the study found that the facilities receive drugs and medical facilities from the National Medical Store Department. However the district councils are ordered to support the provision of health services through their collections. On the other hand, there is no strong basket fund established to support the internal budget for elderly service. Institutions such as family assisted support and social assistance for atleast transport to reach the health facilities. Care for the elderly should be provided within families as there are no plans for institutionalizing old age care ^[17]. However these families should be capacitated with financial support as the initial social institutions to support geriatrics to access free health services.

Identification Cards, few have got identification cards but seem not to be useful. Nevertheless, these cards are not given equally, they are still compromised to others and complaints have risen. A few of older people reported to be charged with money to access it while others had no information whether they are qualified to get the card. Some had national insurance cards, namely the community health fund cards. However, these cards do not cover all the health services to be given. Similarly, this happened in Egypt as one of the studies report that, 66% had not have health insurance coverage (N.d)

In addition, the study aimed to findout the use of social assistance since social assistance is associated with adverse health outcomes and that social assistance recipients exhibit worse health outcomes relative to non-recipients ^[13]. However, not social assistance, is introduced in the selected area which would provide free and equal environments for geriatrics' access to free health. Social justice as fairness regards to the removal of inequalities in access to free health for geriatrics. Satisfaction of institutional framework to favour free health accessibility to older people is little. Currently it was found that there is no legal framework with regard to accessibility of free health services to geriatrics. However this study found that the facilities have managed to establish the campaign of giving first the priority in seeking health services (Elder first-Mpishe Mzee). In one of the interviews, one of the CEO said:-

We have been using normal regulation to protect the geriatrics, however there is no law or Act that goes with implementation of National Ageing policy as addressed. (Field Data, 2023).

The commonly used Laws include the National Health insurance Act ^[16] and National Health insurance fund which are biased to some groups. National health insurance fund provides access to health services only to employees who are at work. Even when they retire from the government aren't given favour to receive free health. The implementation of the National ageing policy is not effective and has been complained. One of the respondent responded that;-

Not all old people are able to pay for the bill. They have been helped by their relatives and it has been difficult to manage this situations. The facilities have have large burden to support and buying medicine for elder people (Interviewee, 2023).

The findings indicate despite the fact that Tanzania government puts the emphasis to local government authorities that they have a role of exempting them from paying for health services; still the policy is not clearly implemented ^[17].

3.2 Mechanism used during identification of geriatrics

The older people are not clearly identified in the villages and there is no proper registration in the village executive offices in recent years. Older adults are major consumers of health care ^[20]. Accuracy data sought to be available so as to enable the local government to build the supporting environment to identify them and understanding whether they are accessible. The available data are to general and concerned the disadvantaged groups who receive the grants from social funds. Among these groups a total of 645 older people were sorted from the selected villages where the study was taken. However, only 52% of 645 older people received treatment using identity cards while 48% had no cards. The processes in identification may lead ineffective implementation as other older people fail to prove their age ^[8]. Older people are expected to be given with free health services at 100% although not all who have an access ^[17]. due to number of reasons. The study, found that the statistical data of geriatrics are compromised as one of the respondents had the following to say:-

We have no older people statistics generally here for the purpose of evaluating how they have been accessing the health services. But when older people data is required we present what we have (Field data, 2023).

Missing critical informaation increases possibilities of inequalities. Similar study was conducted in Ifakara and revealed that, although provision of free health services to older people is stipulated in the Tanzanian National Ageing policy, many older people still do not access these services ^[8]. However, there were no clear mechanisms used to identify the geriatrics with qualifications to access free health services. In only one village the identification was done through the calls announcement by Hamlets.

We managed to identify and register the old people. Hamlets were given a task to identify them in their adminstrative areas. They sent their information to Hamlets for receiving a special identity card. Not all who have identity card, however the number has increased and we don't have a progressive mechanism to identify them (Field data, 2023).

The reason to why some are not identified is the poor communication it was which caused older people inaccess of information during identification. Differently, the study conducted at Kibaha revealed that some could not be identified due to inability to prove their age, and aggravated by the limited availability of health services, equipment and expertise ^[8]. Rawls ^[10] poses opinions that strong political and social institutions have responsibilities of identifying their members and their needs so as to have plan for citizen. Utilisation of resources requires the real statistics of population. This provides the opportunities of proper allocation of resources and social services. The local government officials claimed that there is no mechanism to identify geriatrics which results unclear statistics of people. One of the officials had the following to say:-

We still don't have the exact number of older people (geriatrics) who have got health services through free health programme. However, you can get these information in health facilities like our near dispensary where they usually go for treatment (Field data, 2023).

The process of identifying geriatrics isn't done every year; hence the exact number which may be increasing or decreasing isn't reported. The elder people reports to have no followup and identification took place more than four years.

I rember we were called by Hamlets to present our names for verification in past four years. Since then it is not known. We haven't even received the identification cards which describes ouself when we attend for medication (Field data, 2023).

On the other hand, there was a disparity amongs geriatrics. This was caused by the fact that some of geriatrics had no insuring-identity cards. Older people would have given the cards to identify them, unfortunately most of them haven't these cards which iwas explained to be difficult. The districts were directed to issue cards to older people that would provide information to health providers in health centers ^[3]. Not all who responded to have cards, he study found that there are disparities in cards provision to geriatrics as indicated in Fig. 3.1.

Source: Survey data, 2023

In selected villages, the findings presented in Fig. 3.1 indicate that 1010 out of 2182 had issued with cards while 1172 geriatrics had no identity cards. The difference between those who have and who have not is small. This is an indicator that there is a thin layer between them.

The geriatrics who have cards exceed those who have cards which shows that most of them have no cards. The identification of cards would be endless in the study area as the policy implementation is progress. However it was revealed that there is no progression in providing those IDs despite the demand and the increased population in area. This hinders the provision of free health services to all geriatrics as it was contended by one of older persons.

Currently we have no such programmes, since then we haven't informed to identify those who have no these identify cards. Therefore we still waiting the new circular to provide those identity cards. Once it is announced we are going to announce for those who haven't cards but eligible. (Field data, 2023).

Moreover, the study found that local government collects information of elders using a Health facilities based Statistics where they ask the number of patients in their health facilities. These are older people who in month attend for treatment in health facilities such as hospital or dispensary.

We get information from our health facilities available in our area because when older people are sick the go direct, whether they are identified as needy or not (Survey Data, 2023).

In one of the interviews conducted in health facilities claimed to have older people attendance report both who have cards and those who have no cards. These older people do not come from one area that makes difficult to have a list of older people from the area of the study. Therefore the respective data are found in village executive offices.

We normally receive everyone who is sick. We provide our services to all people who come regardless his or her own citizenship, age, gender, education level or any other status. Therefore it is hard to identify them according to their residential areas. (Interview, 2023).

3.3 Mechanisms for Community, families and elders' sensitisation

Since Ageing is a cross cutting issue, the implementation of this Policy will involve the Central Government, Local Government Authorities, Voluntary Agencies, Families and Villages ^[17]. Local government authorities still have the role to sensitise the community on issues related to older people including free health service and their participation in the national development. This reduces some challenges of discrimination, prejudice and discrimination, since ageist stereotypes and discrimination against older adults have an impact on the health and well-being of older citizens and are potential barriers to health equality ^[20]. The study found that despite the statement of the policy to ensure that geriatrics are sensitised, there is no more mechanisms to sensitise the community members and families on the understanding about the policy itself as well as how it is important to handle older people. These mechanisms to sensitisation would smooth the implementation due to the fact that community needs information for effective policy implementation. Local government as a basic structure to ensure that individuals in the society have informed and are able to participate in health related matters (Rawls, 2002). Few of older people have information about the National ageing policy and its implementation as one of older person responded that:-

I don't have enough information about the ageing policy. I have been listening just to people saying that there is but I never educated to understand what I should do with it. But I have experienced some to be treated free; we still waiting to be identified (Interview, 2023)

The local government authorities claim to use general meetings as mechanisms to sensitization which isn't effective because it always accompanied with other agenda which interferes the deliverance of elders’ specific information. In addition community use poster announcement than other means such as televisions, and radios to access information. One of the last meetings in each of the village once was called indicated the following results presented in Table 3.1

Table 3.1

The status of attendance on general meeting
	Attended	Not attended	Total
Village1	1000	6200	7200
Village2	586	5414	6000
Village3	1530	7470	9000
Village4	1200	6300	7500
Village5	1700	10170	11870
Village6	2400	6390	8790
Village7	1420	8660	10080
Village8	1890	7018	8908
Village9	2089	7311	9400
Total	13815	64933	78748
Source: Survey data, 2023

Table 3.1 indicates only 13815 out of 78748 residents with average of 1535 attend for meeting. It is half of the total estimated to be adults which among them are older people. However it was not noticed with the reason of such reluctant. In all villages the attendance was below the average that justifies little attendance to community meetings.

3.4 Seminars and trainings by professionals for older people's awareness

Thus, while inadequate training in geriatrics remains a problem to solve, it appears that institutions charged with health care education may be progressing in the right direction. This study sought to understand whether the health practitioners have time and planning activities for geriatrics' health education. This would be a source of information, attitudinal change as well as health related problems reduction. The study found that few areas are conducting seminars to geriatrics. Amongst the studied areas confirmed to receive seminars about healthcare and services although with minimal practice as shown in Fig. 3.2

Source: Survey data, 2023

In a given Fig. 3.2 the findings indicate that seminars are provided where although at minimal provision. The figure shows that the provision of seminars is below 50% that only 40% of respondents had received health related issues to geriatrics. However 60% of respondents had not received seminars. In addition, the study sought to understand the stakeholders who were involved. The role of local government will be to sensitise the community, elders and families in collaboration with voluntary agencies. The study found that there were several stakeholders as indicated in Fig. 3.3

Surce: Survey data, 2023

Figure 3.3 presents the findings about the provision of education to sensitise the community and older people themselves about older people's health care. The program of sensitisation is implemented by local government officials, community health workers, voluntary agencies, and health practitioners. However, health practitioners is being involved than the other stakeholders. The response of 35% of respondents indicates that the most useful mechanisms on the study areas depends on health practitioners. On the other hands, local government is involved to sensitise the community. Local government responds to the role to collaborate with other stakeholders to sensitise people about older people's welfare ^[17]. In addition other stakeholders are involved at minimal responses such include community health workers (18%), voluntary agencies (12%) and individuals (5%). The findings shows that the awareness is increasing due to integration services. However, voluntary agencies are not full involved in the studied areas.

There is still no legal framework which is directly enacted for implementing this policy. Absence of these laws drawback the implementation due to the fact that once a person violates about health care services, it is not easily sanctioned. It is confusing to implement the policy which has no clearly stated laws or depending on other non related to health laws. There shall be a law to guide implementers of National Ageing policy ^[17]. The policy since was made has more than ten years without law which means that it is ineffective. Older people need to be secured to access health services free as indicated however the absence of these frameworks interfere the implementation. Quick reforms should be called upon so as to give teeth to this policy so as effect the implementation and to achieve the desired goals. Additionally, there is a need to establish the universal health insurance and strengthen the local government authorities to cover economic disparities and increase the social cohesion in the society. Moreover, this will increase equal opportunities to access healthcare and grant more freedom for geriatrics to access health services.

Identification of geriatrics isn't matching with the policy through which local government has given the roles. Lack of old people data base (elderly statistics) infringes the opportunities of some geriatrics. The implementation of National Ageing policy lacks strong political institutions to support implementation. Moreover, mechanisms used currently to identify older people are confusing. The mechanisms have left other older people without being identified. Provision of cards still biased as it is indicated that not all older people are given with cards. Nevertheless, the cards should be issued to everyone regardless the need of it olders might have. Not necessarily to have identity cards, but the National Id can be used to trace the age and get to understand that this is older and is within a range of specified ages.

Sensitisation is something essential to people for decision making or implementation of certain programs. For effective implementation, implementers or beneficiaries of the program must understand generally the objectives, resources, mechanisms and strategies to implement the particular policy. National ageing policy is challenged due to the fact that few people understand about it. On the other hand efforts to sensitisation is very minimal which hinders the provision of free health services. Good mechanisms should be taken into consideration. Individuals are viewed as less important to engage in sensitisation per the findings. This call for the local government to provide health education to few individuals who will save the sensitisation programs. Moreover, community health workers are very important because they try to do better to ensure that things are get done. Therefore, more attention should be given to capacity building on both fiscal and financial capacity. Local government through social welfare officers should have clear arrangements to visit households so as to assess the geriatrics' needs so as to decide with evidence.

Disclosure of potential conflicts of interest

The authors have no competing interests to declare that are relevant to the content of this article.

Research involving Human Participants and/or Animals

Ethical approval for this research was approved by Mzumbe University Directorate of Research and Publication in Tanzania based on the guidelines of national ethics committees

Informed consent

This paper involved geriatrics. Therefore, since the participants were old people who could not write their consent was solicited through face-to-face discussion and they finally agreed to participate in the interview and focus group discussion.

Funding’ and/or ‘Competing interests

The authors did not receive support from any organization for the submitted work

Data availability statement

The data for this article were collected through interview and secondary sources and the data can be accessed through the following link https://drive.google.com/file/d/1tSJFQ-0ysYfXx8ZNRIUomaefh9D27UV5/view?usp=drive_link”

Author Contribution

WUL- Literature review , data analysis and discussion BK- Research Methodology and discussion of findings and conclusion

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The application of Rawls’ Theory of Justice in providing equitable free Health services to Geriatrics in Tanzania

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Abstract

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1.0 Introduction

1.1 Theoretical Ground

2.0 Methodology

3.0 Results and Discussion

3.1 Institutional, Policy and Internal Legal framework

3.2 Mechanism used during identification of geriatrics

3.3 Mechanisms for Community, families and elders' sensitisation

3.4 Seminars and trainings by professionals for older people's awareness

4.0 Conclusion and Recommendations

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