This study set out to determine the pattern of expenditure among older adults in Ghana, while ascertaining their direct medical costs. The results from this study comes as pertinent for several reasons, especially in a low-middle income country such as Ghana and similar counties in the subregion. Ghana has shown a gradual change in its demographic characteristics due to population ageing (16). The somewhat gradual pace provides valuable lead time for strategic planning and policy development to ensure systems are prepared for the coming changes. Estimates of household expenditure, such as those from this study, could therefore be used to inform policies, with regards to prioritization, health insurance, reimbursements, social services, housing, transportation and agriculture among older persons. Despite considerable attempts to include as many older Ghanaians as possible onto the NHIS, among other policies (8), this study suggests that the NHIS did not significantly reduce the average household expenditure, nor the direct cost on health for households with older adults. These results will therefore feed into efforts to refine and extend coverage of the NHIS so that older adults are included in UHC targets.
It is important to establish that though the pattern of household expenditure holds great predictive value in planning, it is affected by many individual preferences which may be difficult to account for (behavioural heterogeneity) (9). There are also assertions of age-associated health conditions which could increase the household expenditures among older adults.
This study found the average household cost among the study participants to be US$ 1,893. These low estimates, though excluding taxes, are considered characteristic of low income countries which Ghana was, at the time of the study. Furthermore, the average direct medical cost, being US$ 318, accounted for 18.1% of the average total expenditure among the elderly. It has been suggested that at low income levels, spending diversity is low, as food and health care might be expected to dominate spending (9). In corroboration with this, food and healthcare took a proportionate 46% and 18.1% of the total household expenditure among the elderly in this study, the highest among the variables investigated. In comparison to these, average annual health expenditure was estimated to be US$7,439 among older populations in Australia at about the time of this study (10). Also, in this study, 7% of household income was accrued by medications, while an equal amount was spent on herbal/alternative medicines. This further substantiates the high prevalence of alternative/traditional medicine usage among older Ghanaian adults (17).
Aside being a LMIC, the pattern of expenditure among older Ghanaians generally differs from that that of Japan (18), UK (1,14), and the USA (20), due to the entire prevailing social, political and cultural systems. For instance health financing in Ghana is mainly publicly funded through the National Health Insurance scheme (NHIS), which as of the commencement of this study in 2014, covered some 10.4 million Ghanaians, approximating 40% of the country’s population (21). The fairly large coverage, which is free for adults aged 70-plus years, and the ‘core poor’ defined as the unemployed with no visible source of income, no fixed residence, and not living with someone employed and with a fixed residence (22), could significantly have contributed to the comparatively lower out-of-pocket expenditure on health. Also, Ghana has a deep-rooted housing crises which has seen several attempts at reforms over the past few decades (23). With rising cost of rent, cheaper alternatives and settlements, especially in rural areas could be the preference among older adults. The 16% ‘Other’ category (Fig. 1) could be a reflection of the heterogeneity of the study population. Included in this category are taxes, gifts, recreation, among others.
Safeguarding people from catastrophic payments, that is, financial hardship caused by health payments, has come to be a widely accepted index, and a desirable objective in health policy. This study found the prevalence of catastrophic health expenditure among older adults in Ghana to be 4.5%, using a 40% threshold. As catastrophic health spending is generally thought to be rising, our figure relates to the 7% prevalence found in India (15). Over a quarter of the participants had obtained financial assistance, while many of the participants (30%) had salaries being the major source of financing. A significant 34% of older population had to borrow money or sell their property to finance their expenditure. Nearly half of the older population had also not had any formal education, an observation which could inform the policy process and its implementation.