This study set out to determine the pattern of household 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 countries 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.
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 expenditure among the study participants to be US$ 2,459. 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$ 246, accounted for 10% of the average total expenditure. It has been suggested that at low income levels, spending diversity is low, as food and healthcare might be expected to dominate spending (9). In corroboration with this, food and healthcare took a proportionate 35% and 10% of the total household expenditure in this study. 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, 5% of household expenditure was accrued by medications, while 3% was spent on herbal/alternative medicines. This further substantiates the high prevalence of alternative/traditional medicine usage among older Ghanaian adults (17). Compared to younger adults, older adults spent more on transportation and traditional or alternative health therapies. While the elderly are likely to spend more on conveyance, especially for those with mobility related illnesses, the cultural context influences ageing and health practices. Traditional and alternative medicine use is inadmisible to the cultural setting of many people in sub-Saharan Africa, possibly accounting for its significant presence in the household expenditure of older adults in this study (18).
The population characteristics of this study is similar to findings of Issahaku and Neysmith (2013), who also reported that a higher proportion of the elderly in West Africa is female, with many having little or no formal education, and found more in rural areas (19). Comparatively, Ogura and Jakovljevic (2018) also describe the elderly in higher income countries as being mostly female, poor, and living alone (3).
Aside being a LMIC, the pattern of expenditure among older Ghanaians generally differs from that of Japan (20), UK (9,21) , and the USA (22), 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 (23). 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 (24), could significantly have contributed to the comparatively lower out-of-pocket expenditure on health in this study. Also, the 27% expenditure on household and utilities could be a manifestation of the deep-rooted housing crises in Ghana, which has seen several attempts at reforms over the past few decades (25). With rising cost of rent, cheaper alternatives and settlements, especially in rural areas could be the preference among older adults. The 17% ‘Other’ category (Figure 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 7.8%, using a 40% threshold. The catastrophic household health expenditure was reported to be 1.6% from a survey in 1998 (8). As catastrophic health spending is generally thought to be rising, our figure comparatively relates to the 7% prevalence found in India (15). It was also reported to be 22.2% in Iran (26), 6–15% in Burkina Faso (27), and 8–14% in Thailand (28). Nearly 40% of the households had obtained financial assistance, while many (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. These findings necessitates the need for a broader discussion on health financing, as the transition to a more aged society brings considerable financial challenges to any economy (3). Beyond the effective and more tailored implementation of the NHIS, some authors have suggested for the provision of basic income for persons aged 60 years and above (19), while free or subsidized transportation could be considered of the very elderly in the society.
This study is limited by the few variables explored. Also, being cross-sectional, this study provides only point estimates, for which care must be taken in the interpretation of its results. Recall bias, as in many costing studies could have influenced households’ report of expenditures.