Catastrophic health expenditure and household food insecurity among older adults with health conditions in Ghana: a cross-sectional analysis

BACKGROUND: In low- and middle-income countries like Ghana, older adults with health conditions face a double burden of managing illness while simultaneously mitigating the financial toxicity of healthcare, which may negatively impact household food insecurity (FI). However, a critical gap exists in the literature regarding the direct effect of catastrophic health expenditure (CHE) on household food insecurity (FI) in this demographic, despite its policy significance. Thus, this study investigates the association between CHE and household FI among older adults with health conditions in Ghana. METHODS: A cross-sectional analysis was conducted among 6,804 adults aged 50 + with an illness, injury, or disability from the 2022 Annual Household Income and Expenditure Survey (AHIES). FI was measured using a hybrid indicator consolidating expenditure-based (> 60% of income spent on food) and experience-based metrics. CHE was defined as occurring when a household's out-of-pocket health payments exceeded 40% of its capacity to pay for healthcare (income remaining after meeting basic food needs). Multivariable logistic regression was used to estimate the association between CHE and FI and effect modification by wealth, adjusting for key sociodemographic factors, including age, sex, wealth quintile, marital status, occupation, and place of residence. RESULTS: The overall prevalence of FI was 50.2% among the sample. CHE was a strong predictor of household FI. After adjusting for covariates, the association remained strong and significant; incurring CHE was associated with a 5.88-fold increase in the odds of FI (AOR = 5.88, 95% CI: 2.31-14.93). The association of CHE with FI was significantly stronger among those in the 'poorer' wealth quintile (AOR for interaction = 2.38, p = 0.007) compared to the poorest, identifying this near-poor group-the 'missing middle'-as disproportionately vulnerable. CONCLUSION: CHE is a significant driver of FI among older, unwell Ghanaians, with effects disproportionately affecting those in the poorer wealth quintile. Policy efforts must advance beyond expanding health insurance enrollment to strengthen financial protection and integrate nutritional support for at-risk older adults, particularly those in the 'poorer' wealth quintile (the 'missing middle') who face the highest vulnerability to health-induced food insecurity.