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How did Ghana respond to the COVID-19 pandemic?

The following section covers the interventions that were deployed in Ghana between March 2020 and December 2021 to respond to COVID-19 and maintain essential health services. Interventions during the early phases of the COVID-19 pandemic in Ghana fell into three main categories: national, governmental, and population-level measures; health system–level measures; and patient-level measures.

Exemplars in COVID-19 conceptual framework for assessing epidemic preparedness and response

Even before the first case of COVID-19 was reported in Ghana on March 12, 2020, health officials acted to keep the novel coronavirus from entering the country. For instance, travel for state officials was banned, and Ghanaians in Wuhan, China, were not allowed to return in the early months of the pandemic.1

As soon as health workers detected those initial cases, authorities activated an emergency preparedness and response plan aimed at detecting, containing, and delaying the spread of COVID-19.2,3,4  This was a familiar process: Ghanaian officials had established similar plans for previous health emergencies, such as the Ebola virus disease outbreak of 2016.5 

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The emergency preparedness and response plan provided a road map for officials to coordinate Ghana’s pandemic response. At the national level, it provided guidance on establishing a National Technical Coordinating Committee (NTCC) supervised by the director general of the Ghana Health Service,6,7   whose members were representatives from public agencies, international development partners, and research institutions such as the Noguchi Memorial Institute for Medical Research and the School of Public Health at the University of Ghana, to oversee the response.8 The NTCC organized subcommittees to design pandemic response activities in seven key areas:7

  • Coordination of logistics and operations
  • Case management and rapid response
  • Surveillance at points of entry and cross-border surveillance
  • Epidemiological surveillance and data collection, analysis, and reporting
  • Risk communication and social mobilization
  • Laboratories and logistics
  • Infection prevention and waste management

The NTCC also established a national Emergency Operations Centre to implement the NTCC’s plans in four key thematic areas: surveillance, laboratories, case management, and risk communication.8

Officials also activated public health emergency management committees and rapid response teams at regional and district levels.8

In mid-March 2020, officials began to implement the policies the NTCC designed:

  • At points of entry, staff adapted a health declaration form they had previously been using to detect Ebola virus disease in incoming travelers. They also used thermal scanners and thermometers to take the temperature of travelers and restricted entry from countries with more than 200 reported cases of COVID-19.8 Borders with Togo, Cote d’Ivoire, and Burkina Faso were closed. International flights were suspended.
  • Authorities declared a three-week lockdown in the Accra and Kumasi metropolitan areas where COVID-19 was spreading rapidly.
  • Schools were closed and social gatherings were banned.

To support Ghana’s COVID-19 response, a coalition of civil society and community organizations—including private-sector entities such as banks, companies and industries, pharmaceutical companies, and wealthy individuals—donated money and key goods such as personal protective equipment (PPE) and test kits. Researchers note that the Ministry of Health also established a COVID-19 strategic plan and budget, initially more than US$600 million. The plan included laboratory, surveillance, case management, infrastructure, risk communication, and social mobilization.

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Ghanaian authorities implemented strategies to maintain the delivery of essential health services as soon as flagging performance across essential health service indicators made it clear they were necessary.

Interventions to limit the spread of COVID-19 and maintain essential health services during the early stages of the pandemic in Ghana fell into three main categories:

  • National, governmental, and population-level measures
  • Health system–level measures
  • Patient-level measures

National, governmental, and population-level measures

The Ghanaian health system’s experience with previous outbreaks of infectious disease, such as Ebola virus disease and cholera, meant that it already had key tools for public health risk communication that could be adapted for COVID-19.5,9 In March 2020, the Ghana Health Service, National Commission for Civic Education, and Ministry of Information aligned to provide high-quality, coordinated messaging on the COVID-19 pandemic including case counts, preventive measures, policy announcements, and other key information. The country’s president began to brief the public regularly, as did ministerial officials.8 Official websites and postings on social and traditional media complemented these risk communication activities.

Information was coordinated through regular presidential addresses, minister’s press briefings, dedicated COVID-19 websites, and social and traditional media. A COVID-19 task force was formed to train and coordinate risk communication to Ghanaians.

These official risk communication activities had an especially important role to play in the face of the early spread of “fake news,” conspiracy theories, and falsehoods about the novel coronavirus—particularly on social media. For instance, some Ghanaians did not believe that COVID-19 existed at all. Social media reports suggested that health authorities invented or inflated case counts to receive more funding from donor agencies such as the World Health Organization (WHO) and the World Bank.

COVID-19 signs and warnings at a pharmacy in the University of Ghana Medical Center in Accra, Ghana, on June 24, 2022.
COVID-19 signs and warnings at a pharmacy in the University of Ghana Medical Center in Accra, Ghana, on June 24, 2022.
Credit: Nana Kofi Acquah. Copyright: © Gates Ventures, LLC.

Officials and “influencers” working with the health system used print and electronic media—including television, radio, email, Facebook, Twitter, WhatsApp, and newspapers—to communicate with the public (in the official language, English, and other languages spoken in Ghana). They also developed materials such as billboards, leaflets, epidemiological bulletins, documentaries, and infomercials to provide clear and accurate information to as many Ghanaians as possible.10   The Ghana Health Service created a telephone hotline that citizens could call to get emergency assistance, report suspected cases, and receive guidance on treatment and diagnosis.

In some areas, health authorities and security officers also visited communities to monitor public adherence to COVID-19 protocols and encourage people to visit health facilities if they needed to.

Ghana’s COVID-19 response was focused primarily on: testing, tracing, and treating suspected cases and high-risk individuals. However, officials also implemented a battery of public health and social measures as part of the health system’s immediate pandemic response. For example, to limit the importation and transmission of COVID-19, Ghana closed its air, sea, and land borders as well as schools, churches, mosques, bars, and other social venues. Supermarkets and restaurants adopted enhanced hygiene protocols.1

On March 30, 2020, officials established partial lockdowns in COVID-19 “hotspots,” mostly in Greater Accra and Greater Kumasi. They asked an estimated 6 million people to stay at home except to shop for food, medicine, and water and visit public toilets or the bank.12 Essential workers were exempted from the restrictions. Three weeks later, on April 19, Ghana became the one of the first African countries to lift the lockdowns it had imposed.13 Officials argued the lockdowns were no longer necessary because data showed they had successfully contained the spread of the virus and because they had enhanced the country’s testing program, identified potential hotspots, and established treatment centers across the country.14

In June 2020, Ghana’s government enacted legislation to punish those who failed to wear masks in public: violators could receive up to 10 years in prison or a fine of 60,000 Ghanaian cedis (approximately US$4,686).15,16 Officials also deployed security forces (including army and police) to enforce social distancing protocols, mandatory mask wearing, and other measures aimed at mitigating COVID-19.

Ghana’s airports reopened in September 202017 and schools reopened in January 2021,18 but land and sea borders remained closed until March 28, 2022. 19

Adherence to public health and social measures varied. According to the Ghana Health Service, the highest rates of adherence to containment measures were self-isolation for symptomatic people (70%) and school closures (80%) between March 2020 and September 2021, whereas adherence to handwashing, mask wearing, and social distancing measures decreased over time.

Case study: The impact of COVID-19 school closures in Ghana

Students wear face masks in class at the New Edition School in Kasoa, Ghana, on July 4, 2022. Credit: Nana Kofi Acquah.
Students wear face masks in class at the New Edition School in Kasoa, Ghana, on July 4, 2022. Credit: Nana Kofi Acquah.
Copyright: © Gates Ventures, LLC.

As in many countries, Ghana closed schools for students of all ages starting in March 2020 to contain the spread of COVID-19.11 Students in their final years of junior and senior high school were exempted at first because they had examinations to prepare for, but the West Africa Examination Council indefinitely postponed their tests in April 2020 and those students were sent home.20   According to the World Bank, these closures affected more than 9.2 million students in primary and secondary schools, a half million university students, and 450,000 teachers.21

To ensure the continuity of teaching and learning while schools were closed, the Ministry of Education and the Ghana Education Service introduced distance and online learning platforms including television, radio, and printed take-home lessons for nearly 3 million students who did not have access to online or electronic technologies.22,21

Read more: World Bank – Ghana: online education for delivering learning outcomes during the COVID-19 school closure

The country faced some challenges associated with the transition to distance learning, especially online. Low levels of computer literacy and access to high-speed internet, high costs of digital devices and internet access, and unstable electricity kept many from schooling, which in turn amplified existing educational inequalities, especially in rural areas.23,24,25

Since 2020, researchers have tried to measure the intended and unintended consequences of school closures and e-learning in Ghana. A 2020 study on e-learning found that Ghanaian parents with lower socioeconomic status were less ready to support their children at home than wealthier parents. Another study used a longitudinal data set to estimate learning loss during the three-month transition from complementary basic education (primary and secondary school) to government schools (senior secondary school and university) in Ghana and found an average learning loss of 66% of previous learning gains in foundational numeracy. 27 Furthermore, findings showed that lack of support and resources for at-home learning contributed to widening the gap in learning loss. This implied that the learning gains obtained from foundational numeracy skills before the pandemic could be completely lost in the absence of successful supports for learning at home during COVID-19 school closures.

University students encountered similar challenges. The Ministry of Education facilitated zero-rating (free data use) for most educational platforms for most of the tertiary institutions in the country to ensure that the cost of data did not keep students from participating in e-learning, and institutions of higher education implemented initiatives to provide students with internet data for online learning. For example, the University of Ghana and Vodafone Ghana offered data and talk time for online studies for on-campus students. However, if students left campus, they had to buy their own data to have access to online courses.

A 2021 study found that the high cost of internet data off campus, slow internet connectivity, student concern about the quality of online learning, weak technical supports, and lack of motivation to learn were among the main challenges faced by students at the University of Ghana in remote learning during school closures.28,29 Other researchers surveyed a cohort of students at the University of Health and Allied Sciences in Ghana and found that more than half (62.9%) were not ready to use e-learning platforms (such as Moodle, Google Classroom, Zoom, and others),30,31   and only 36.5% had prior experience with those platforms before the COVID-19 pandemic.32

The situation was no easier for teachers. Research showed that many teachers in senior high schools in the northern region of Ghana lacked the skills to deliver online learning, and that most classrooms were not connected to the electricity necessary to support it.33 A survey conducted among tutors in a college of education revealed that more than two-thirds needed more training to be able to deliver confident, effective online lectures.34 Another study found that most private schools were not able to pay their staff during the pandemic, and many private-school teachers were laid off.35

School systems around the world have identified the adverse effects of school closures on educational and non-educational outcomes.36,37,38,39 However, many of these adverse consequences have not yet been quantified in Ghana. A nationally representative household survey found that school closures had a negligible effect on dropout rates (only 2% of previously enrolled children dropped out of school during the pandemic, the same as pre-pandemic rates), but children from lower-income homes were more likely to drop out during the pandemic.40 There were also reports of increased teenage pregnancy during school closures.41

The United Nations Children’s Fund in Ghana worked closely with the government to protect children as they spent more time online during the pandemic, including:

  • Raising awareness among children, teachers, and caregivers to prevent online abuse and exploitation via the Safer Digital Ghana Awareness Programme that was established in 2018.
  • Launching a cybercrime/security incident reporting portal to facilitate incident reporting.
  • Establishing a digital forensic laboratory for the Cyber Crime Unit of the Ghana Police Service.
  • Comprehensive legal reforms to strengthen the protection of children from all forms of abuse, including online exploitation.
Students wear face masks during class at the New Edition school in Kasoa, Ghana, on July 4, 2022.
Students wear face masks during class at the New Edition school in Kasoa, Ghana, on July 4, 2022.
Credit: Nana Kofi Acquah. Copyright: © Gates Ventures, LLC.

Mobility in Ghana—especially via public transit—decreased sharply during the first months of the pandemic: research found that the “trotro” paratransit service saw marked declines in patronage due to social distancing protocols.42 Key informants suggested that government legislation to limit the number of passengers on paratransit services decreased patronage. They also noted that many people voluntarily avoided public transit because their fellow riders were not wearing face masks and because they were worried about the cleanliness of the vehicles.

Change in relative mobility compared to pre-pandemic baseline from March 2020 to December 31, 2021

IHME COVID-19 Projections

These reductions in mobility likely limited COVID-19 transmission, but they may have also limited economic activity and introduced barriers to the delivery of essential health services.

Case study: Modeling the impact of public health and social measures on the COVID-19 pandemic in Ghana

COVID-19 restrictions on seating at the University of Ghana Medical Center in Accra, Ghana, on June 24, 2022. Credit: Nana Kofi Acquah.
COVID-19 restrictions on seating at the University of Ghana Medical Center in Accra, Ghana, on June 24, 2022. Credit: Nana Kofi Acquah.
Copyright: © Gates Ventures, LLC.

The public health and social measures Ghana implemented to reduce COVID-19 morbidity and mortality likely undermined the provision of essential health services. However, few studies had simultaneously explored the effectiveness of these measures in reducing the transmission of COVID-19 and their relative effect on deaths through provision of essential health services.

As part of this investigation, a study by the University of Ghana School of Public Health sought to assess and compare the effect of public health and social measures on Ghana’s pandemic outcomes: the number of new infections and case fatality rates, the impact on business continuity, and essential health service indicators such as immunization rates and utilization rates for selected child, neonatal, and maternal health services.

Researchers hypothesized that the pandemic had immediate and sustained impacts on the provision of essential health services in Ghana, and that public health and social measures were associated with reduced transmission of COVID-19. They adapted the model from the COVID-19 International Modelling (CoMo) Consortium43 to identify which interventions or combination of interventions (including lockdowns, school closures, vaccination, and border closures) had the greatest influence on COVID-19 incidence and deaths and compare them with the counterfactual of doing nothing. The CoMo model is an age-structured compartmental susceptible-exposed-infected-recovered-susceptible model that stratifies symptoms, severity, treatment-seeking behavior, and access to general health care and emergency services.

Across the board, modeling efforts consistently showed the importance and effectiveness of public health and social measures in slowing the spread of COVID-19 in Ghana. The most efficient top-down measures were banning public gatherings, limiting social gatherings, school closures, remote working, and lockdowns. Only the stay-at-home intervention did not appear to result in a protective effect.

The model estimates suggested that the public health and social measures and vaccination programs had been effective, indicated by the decline in the trend of effective reproduction numbers, new cases, and COVID-19-induced deaths. Public health and social measures and vaccination programs reduced hospital surge bed occupancy, admissions to intensive care units, and the severity of infection (measured as the total number of patients who required ventilators to survive).

Among all the public health and social measures that were implemented, the ban on international travel and the partial school closure averted a higher number of deaths and new cases, respectively. Higher vaccination coverage was associated with a lower number of new cases and COVID-19-induced deaths. Modeling also showed that the timing of public health and social measures was a critical factor in their effectiveness. See below for a model on how public health and social measures impacted predicted changes in the number of deaths due to COVID-19.

 

Impact of Vaccination and other public health and social measures of COVID-19 (2020-2021)
University of Ghana School of Public Health
A teacher helps a student put on her face mask during class at the New Edition School in Kasoa, Ghana, on July 4, 2022.
A teacher helps a student put on her face mask during class at the New Edition School in Kasoa, Ghana, on July 4, 2022.
Credit: Nana Kofi Acquah. Copyright: © Gates Ventures, LLC.

Although Ghanaian officials encouraged people to wear face masks starting in March 2020, it was not until June of that year that the president enacted legislation to mandate mask wearing.15 That rule, an extension of one that had been in place in Accra and its metropolitan area since April 2020,44 punished those who failed to wear masks in public: violators could receive up to 10 years in prison or a fine of 60,000 Ghanaian cedis (approximately US$4,686).16

Mask use in Ghana from March 2020 to December 2021

*Percentage of the population who say they always wear a mask in public; IHME COVID-19 Projections

Research found that early in 2020, some seamstresses and tailors began to make and sell cloth masks for people to wear in public places like workplaces and shops.45 However, key informants reported that a limited supply of PPE, including disposable face masks, kept health workers from performing their jobs safely. Likewise, one study found that inadequate supplies of PPE made it difficult for health workers (and especially nonclinical staff) to comply with guidelines encouraging masking, gloves, and regular handwashing.46

According to key informants, compliance with mask mandates and other protective measures among the general population saw a large urban-rural divide: people in urban settings were more informed about COVID-19 and reported better preventive practices. Likewise, people with higher levels of education were more likely to comply with public health and social measures.

On March 28, 2022, in response to rapidly declining case counts, Ghana’s government announced that it was no longer mandatory to wear face masks indoors.47

Although evidence from around the world shows that public health and social measures helped to flatten the epidemic curve early in the COVID-19 pandemic,48 interventions such as local mobility restrictions and travel bans also had profound negative economic effects. This proved to be true in Ghana as well.49

Almost every sector of Ghana’s economy was negatively affected by lockdowns and other public health and social measures in March and April 2020. Early in the COVID-19 pandemic, the country saw a substantial shortfall in oil revenue, customs receipts, and non-oil, non-tax revenues along with an increase in health-related expenditures.50 Workers in the informal sector—such as rickshaw drivers, street vendors, repair service workers, and waste pickers as well as workers in urban marketplaces—were among the hardest hit.51,52 Their income fell considerably, especially during the lockdowns in March and April 2020.53 Many workers in the tourism industry also lost their jobs,54 small construction firms saw severe interruptions in cash flow,55 and even the insurance industry suffered in the early months of the pandemic.56

The government of Ghana moved to mitigate these adverse economic impacts in several ways:

  • Officials distributed hot meals to some 400,000 vulnerable households during the March and April 2020 lockdowns in Greater Accra and Greater Kumasi. They also provided dry food packs for nearly 470,000 families.8
  • Ghanaian authorities subsidized all water bills for six months starting in April 2020. They also provided free electricity to vulnerable people for nine months, until December 2020, and cut electric bills for all other residents and businesses in half.8
  • Due dates for income-tax returns were extended and Ghanaians were allowed to deduct donations of money, equipment, and goods related to COVID-19.
  • Health workers received extra financial incentives: pay bonuses, tax exemptions, and insurance coverage. Some health workers in Accra, Kumasi, and other cities received free transportation to and from work.8
COVID-19 and mental health in Ghana

Even though public health and social measures proved to be effective in Ghana, they came at a cost. Research highlights the detrimental impact of COVID-19 on mental health and emotional well-being.

For example, researchers reported adverse mental health impacts of measures in response to COVID-19 including boredom, anxiety, and stress. One survey investigated the prevalence and changes in boredom, anxiety, and psychological well-being before and during the COVID-19 pandemic and found an increase in symptoms of generalized anxiety disorder (from 11.6% before the pandemic to 23.1% during the pandemic) and boredom (from 29.6% to 43.2%). 57 Another study estimated that three-quarters of practicing radiographers in Ghana experienced work-related stress during the pandemic, which many attributed to the scarce availability of the PPE they needed to feel safe at work.58 Other research found evidence of psychological distress (depression, anxiety, and stress) associated with the fear of contracting COVID-19 among 209 university students in Ghana59 and among small business owners awaiting government support.60

 

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Ghana’s primary response to the COVID-19 pandemic—to detect cases early, treat infected people, and stop the spread of COVID-19 into and within the country—relied in large part on tools and systems for disease surveillance. Key informants noted that many of these tools predated the COVID-19 pandemic, including:

  • A national network of district-level laboratories as well as three research laboratories—the Noguchi Memorial Institute for Medical Research, the Kumasi Centre for Collaborative Research in Tropical Medicine, and the National Public Health and Reference Laboratory—experienced at diagnosing infectious pathogens and identifying disease outbreaks.61
  • A centralized and routine data reporting system, the District Health Information Management System (DHIMS), that enabled health professionals to capture disease outbreaks in near real time.62
  • The frontline Field Epidemiology Training Program (FETP), established in 2014, designed to strengthen the capacity of district and subdistrict health workers (and animal health workers) in public health surveillance and emergency response. This frontline FETP is part of a broader FETP in Ghana, which was established in 2007 to train field epidemiologists. Ghana’s FETP has helped investigate more than 180 disease outbreaks in total.63
  • Standard operating procedures for collecting, packaging, and transporting samples for diseases under surveillance.
  • Routine surveillance for influenza-like illnesses in 27 sites across Ghana, coordinated by the National Influenza Centre in the virology department of Noguchi Memorial Institute for Medical Research,64,65,66 which served as a blueprint for Ghana’s response to the COVID-19 pandemic.

Additionally, Ghanaian health services used the Surveillance Outbreak and Response Management and Analysis System (SORMAS), a centralized data reporting system developed in Nigeria, to track COVID-19 cases in real time in resource-limited settings. Health and laboratory workers collected and compiled digital data—including case counts and positive and negative COVID-19 tests—in SORMAS, which enabled easy data sharing with all levels of the health system and with the media.

Read more about SORMAS in Nigeria here: https://www.exemplars.health/emerging-topics/epidemic-preparedness-and-response/digital-health-tools/sormas-nigeria

These preexisting tools and systems had some shortcomings, however, such as limited infrastructure (including internet connectivity for data reporting systems), supplies (including tablets and testing equipment and reagents), and capacity for data coordination.

Before health workers confirmed Ghana’s first cases of COVID-19 in March 2020, the disease surveillance department of the Ghana Health Service devised a strategy to repurpose the sentinel surveillance system for tracing, testing, and treating infected and high-risk people with influenza-like illnesses.67 To prevent COVID-19 from entering the country, the Ghana Health Service and the FETP organized trainings at the Kotoka International Airport and other points of entry in laboratory testing, symptom monitoring, and quarantine enforcement.8 The Ghana Health Service and FETP staff and alumni were also trained in contact tracing for COVID-19.68,67

Other approaches to COVID-19 surveillance in Ghana included:

  • Active surveillance: During the partial lockdown starting on March 30, 2020, in Greater Accra and Greater Kumasi, the Ghana Health Service performed active case searches and contact tracing. Through this active surveillance approach, health authorities identified 63% of confirmed cases—93% of which were asymptomatic. 67
  • Passive surveillance: This includes voluntary walk-in screening for COVID-19 at health care facilities and testing centers.
  • Aggregated routine surveillance: Health authorities created a public online dashboard drawing from DHIMS data that included case and death counts, hospitalizations, and hospital discharges, in the aggregate and by age group.69
  • Syndromic (clinical) surveillance: In the early months of the COVID-19 pandemic, Ghana adopted and strictly followed the WHO recommendations for case identification and testing, and health authorities encouraged individuals who experienced some of the symptoms of COVID-19 (such as cough, difficulty breathing, and loss of taste and smell) to report to the nearest health facility. Hospitals, clinics, and health centers also identified suspected cases.70
  • Virological surveillance: PCR testing was the main tool used to detect COVID-19 cases in Ghana.
  • Digital surveillance: Ghana developed a COVID-19 tracker that individuals could use to assess and report their own symptoms to health workers via the app or website.71 The tracker also used crowd-sourcing data to share location information for confirmed COVID-19 cases to help health authorities identify hotspots and high-risk communities.72
  • Genomic surveillance: Genomic sequencing of SARS-CoV-2 by Ghanaian scientists73 informed policy decisions such as mandatory quarantine.

 

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In general, key informants noted that official decisions to implement public health and social measures to slow the spread of COVID-19 relied in large part on surveillance data and WHO recommendations. For example, the Ghana Health Service sought the support of external experts and relied on Ghanaian infectious disease modelers to assess the effectiveness of different interventions. These models, which also forecast or predicted different epidemic scenarios, helped officials discern where to direct scare resources for the greatest impact.

The success of Ghana’s “3T strategy”—tracing, testing and treatment—depended on sufficient testing capacity. However, key informants reported that in March 2020, only two laboratories could perform PCR tests for COVID-19: Noguchi Memorial Institute for Medical Research in Accra and the Kumasi Center for Collaborative Research in Tropical Medicine.8 This limited testing capacity led to early backlogs of samples and a relatively long turnaround time for test results (four to five days).46,74

Contact tracing in Accra and Kumasi in April 2020 resulted in overwhelming numbers of suspected COVID-19 cases—far more than the two specialized laboratories could handle per day if they tested each sample individually.

Dr. Bernard Nii Akrashie Attoh takes a swab sample from patient, Cindy Deladem Dornyoh, for a COVID-19 test at the University of Ghana Medical Center in Accra, Ghana, on June 23, 2022.
Dr. Bernard Nii Akrashie Attoh takes a swab sample from patient, Cindy Deladem Dornyoh, for a COVID-19 test at the University of Ghana Medical Center in Accra, Ghana, on June 23, 2022.
Credit: Nana Kofi Acquah. Copyright: © Gates Ventures, LLC.

To broaden testing coverage, in August 2020, health authorities sent drones to collect and deliver biological samples from suspected COVID-19 patients in remote areas to the laboratories in Kumasi and Accra.75 Drones could deliver approximately 15,000 test samples each day, and laboratories could deliver test results to patients via SMS.1 (Drone technology was later used to deliver COVID-19 vaccines to remote areas. By 2021, drones had made 185,873 successful deliveries, including medicines, blood products, vaccines, and COVID-19 samples.76 )

 

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To further expand the country’s testing capacity, the Noguchi Memorial Institute for Medical Research and the Kumasi Centre for Collaborative Research in Tropical Medicine hired new staff and kept their laboratories open 24 hours per day. Over time, additional laboratories—public, private, and even the laboratory at the Veterinary Services Department—also came online to reduce testing turnaround time. By April 2020, 16 laboratories in Ghana were able to perform PCR testing for COVID-19.8

The Ghana Health Service also adopted a pooled testing strategy for testing large numbers of samples in a short time using limited supplies. Technicians pooled 10 to 20 samples into a single composite sample, which they tested via PCR. If the result was negative, it meant that every individual whose sample was pooled in the composite had tested negative. If a composite sample tested positive, each sample in the composite was tested separately to determine which individuals had been infected. According to one key informant, this pooled testing strategy made it possible for up to 5,000 samples to be tested per day.8,70,77

Following WHO guidelines established in March 2020, people were released from Ghana’s COVID-19 care pathway after two negative PCR tests at least 24 hours apart. However, rising testing costs, increased workloads, and increasing numbers of healthy patients in treatment centers pushed officials to revise this discharge policy in June 2020. Mandatory exit testing stopped78 and infected people were allowed back to work after 14 days if they were not feeling sick, according to a key informant.

Starting in July 2020, to further reduce testing turnaround time and prevent a backlog of untested samples, the Ghana Health Service focused its testing and tracing efforts on symptomatic people seeking care at hospitals, contacts of people who tested positive, and exposed health workers, students, and travelers.79 This new policy dropped testing rates to nearly zero in some parts of the country.80

That same month, officials increased molecular screening for clinical cases using GeneXpert equipment the country already had as part of its tuberculosis prevention program.81 According to a key informant interview, PCR testing remained the standard, but antigen tests were acceptable for symptomatic patients; however, positive antigen tests still required PCR confirmation. By December 2021, Ghana had 39 registered facilities that could perform PCR and antigen testing.

Laboratories certified to test for COVID-19 in Ghana, November 2021

Ghana Health Services

In August 2020, officials implemented rapid diagnostic testing using immunofluorescent assay technology as a tool for reopening Kotoka International Airport in August 2020.8 New rules required that all arriving passengers must have a negative PCR test from an accredited laboratory in their country of origin and a negative antigen test in the airport terminal. (The test cost US$150, which travelers had to pay.)82 However, after citizens protested about the high costs of these tests, the government reduced the cost to US$50 for Ghanaians and citizens of the Economic Community of West African States. 83

In 2020 and 2021, Ghana made substantial progress in curbing the transmission of COVID-19 using laboratory testing. However, key informants argued that the pandemic exposed the weaknesses of the country’s laboratory network—particularly in health emergencies. They recommended that strategic procurement, prioritization, and stockpiling of laboratory supplies along with crucial investments in laboratory infrastructure and human-resource capacity should be key elements of Ghana’s response to future outbreaks of infectious disease.

Starting on March 12, 2020, Ghanaian health workers identified and followed up with all people known to have direct contact with a confirmed COVID-19 case. Identified contacts were quarantined and monitored for 14 days in designated isolation centers and hotels for those coming from abroad. A week later, the Ghana Health Service published a COVID-19 Self-Quarantine Guide,84   and surveillance officers followed up with those in self-quarantine via phone or physical visits. In April, the Ministry of Health launched a COVID-19 tracker app to facilitate contact tracing and enable symptomatic people to access the care they needed.85

 

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In June 2021, after a surge in the number of active cases in some cities, health officials re-established community contact tracing and testing in those areas.86

Key informants reported that the stigma associated with testing positive for COVID-19 was a major challenge associated with Ghana’s contact-tracing program. For example, people sometimes denied having contact with those known to have tested positive, limiting the program’s reach. Nevertheless, while contact-tracing programs were active, they likely contributed to reducing the spread of the virus.
Community health worker Precious Attah administers a COVID-19 vaccine during a house call to Mary Aidoo in Kasoa, Ghana, on June 27, 2022.
Community health worker Precious Attah administers a COVID-19 vaccine during a house call to Mary Aidoo in Kasoa, Ghana, on June 27, 2022.
Credit: Nana Kofi Acquah. Copyright: © Gates Ventures, LLC.

On February 24, 2021, Ghana became the first country in sub-Saharan Africa to receive 600,000 doses of the AstraZeneca vaccine from COVAX. Vaccine distribution began on March 1, 2021. By April 2, 2022, the country had administered 13.2 million doses 87 of AstraZeneca, Sputnik V, Moderna, Pfizer-BioNTech, and Janssen vaccines (equivalent to 38 doses per 100 people).

 

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In October 2020, Ghana’s Ministry of Health and the Ghana Health Service introduced the Ghana COVID-19 Emergency Preparedness and Response Project to enable affordable and equitable access to COVID-19 vaccines and effective vaccine deployment in Ghana.7

Share of people who received at least one dose of the COVID-19 vaccine

Our World in Data

Case study: Vaccine hesitancy in Ghana

A nurse prepares a vaccine at the Kokrobite Health Center in Kokrobite, Ghana, on June 24, 2022.
A nurse prepares a vaccine at the Kokrobite Health Center in Kokrobite, Ghana, on June 24, 2022.
Credit: Nana Kofi Acquah. Copyright: © Gates Ventures, LLC.

Although vaccination is considered one of the best methods for controlling and preventing the spread of COVID-19, many people in Ghana (and around the world) have been reluctant to receive the COVID-19 vaccine.

Two surveys conducted in Ghana in January and February 2021 assessed the COVID-19 vaccine acceptance level among health workers, with contrasting results. The first found that just 39% of 234 health care workers in Ghana intended to receive the COVID-19 vaccine, with many respondents expressing concerns about its safety and side effects.88 The other found that 59.3% of 108 radiographers were willing to get the vaccine to reduce the spread of infections and reduce mortality from the disease.89 The remaining 40.7% who expressed hesitancy stated doubts about the vaccine’s efficacy and side effects, conspiracy theories about its effects on the Ghanaian race, and fertility concerns.

Similarly, two online surveys conducted in February 2021 looked into COVID-19 vaccine hesitancy among the Ghanaian general population. One found that about half of 2,345 adult Ghanaians were willing to take the vaccine if it was made available to them, whereas 21% were unlikely to take it and 28% were undecided.90 Factors associated with increased vaccine acceptance were gender, age, and education: male high school graduates older than 55 were the most likely to get the shot. The second survey found that about 54% of 1,000 adult Ghanaians reported they would accept the COVID-19 vaccine.91 Logistic regression analyses showed that being married, a salaried worker, and perceiving oneself as high-risk increased the odds of vaccine acceptance in that study.

By the end of 2021, more than 17% of Ghanaians had received at least one dose of the COVID-19 vaccine 92 and 7% had completed the entire initial vaccination protocol.93 In addition, vaccine acceptance among Ghanaians had improved: 7 out of 10 people said they had received at least the first dose of the vaccine or planned to receive it.94

To achieve herd immunity in Ghana, key informants argued that key stakeholders in the health sector should increase targeted public education, curb vaccine misinformation, and raise awareness about the individual and collective benefit of vaccinations, especially among younger people.

 

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Health system–level response measures

In general, key informants noted that although the COVID-19 pandemic placed great strain on Ghana’s health system in some ways, it strengthened it in others. Pandemic-related innovations and adaptations brought the country a new infectious disease center, additional sites for laboratory testing, a greater capacity for mobile health, and a better sense of the gaps and challenges that persisted within the health system.

Between March 2020 and December 2021, Ghana’s health system–level response measures fell into two main categories: direct responses to COVID-19 and interventions to maintain essential health services.

How Ghana maintained health services even during peak COVID

Supply- and demand-side barriers to maintaining essential health services in Ghana during the COVID-19 pandemic

In almost every country in the world, the COVID-19 pandemic and efforts to mitigate it caused supply- and demand-side barriers to the delivery of essential health services. In Ghana, fear and health worker burnout were notable obstacles to maintaining essential health services, especially in the early months of the pandemic.

Fear

In the early months of the COVID-19 pandemic, frontline health workers and prospective patients alike reported they were afraid of contracting the virus at health facilities. (Hospitals were initially classified as high-risk areas.) As a result, both groups avoided those facilities, leading to a tremendous initial decline in health service utilization across the country—even in places that were least affected by the pandemic.

Health worker burnout

In the early months of the pandemic, Ghana’s health workforce worked impossibly long days, and those not classified as “frontline” workers did not benefit from government incentives such as extra pay and tax rebates. Lack of PPE and failure to adhere to COVID-19 protocols in many health facilities contributed to high absenteeism among health workers. Low levels of staffing led to long waits in health facilities, which contributed to patients’ unwillingness to seek care.

In the years before the COVID-19 pandemic, Ghana’s health system made some substantial improvements in health indicators. For instance, life expectancy at birth increased from 62 years in 2010 to 66 years in 2019. The under-five mortality rate per 1,000 live births dropped from 80 in 2008 to 46 in 2019, the neonatal mortality rate per 1,000 live births dropped from 30 in 2008 to 23 in 2019, and the maternal mortality ratio per 100,000 live births dropped from 634 in 1990 to 308 in 2017.95

Unfortunately, initial disruptions to essential health services during the early stage of the pandemic interrupted some of these improvements. A trend analysis conducted by the University of Ghana as part of this investigation found declines in outpatient department and antenatal care services, elective surgeries, tuberculosis services, HIV services, Child Welfare Clinic, malaria, postnatal care, hypertension, and childhood vaccination services..

The trend analysis also found that these indicators rebounded briefly, then dropped again around September 2021 (the onset of the Delta variant). That month, the Partnership for Evidence-Based Response to COVID-19 surveyed 1,280 Ghanaians by telephone and found that only one in eight of the respondents reported missing or delaying hospital visits due to the fear of contracting COVID-19.94 However, about 60% had missed visits for reproductive, maternal, or child health services because of this fear.

Read more: Africa CDC – Finding the Balance: Public Health and Social Measures in Ghana

Read more: PERC – Responding to COVID-19 in African Member States: Ghana

Quantitative analyses, however, found no evidence of significant lasting disruptions in the provision of essential health services in Ghana, likely because of the interventions implemented to avert them.

The charts below illustrate a trend analysis by the University of Ghana of coverage for each of the selected services before and after the beginning of the COVID-19 pandemic in Greater Accra. The red line, a counterfactual, predicts what might have happened in the absence of the pandemic.

Impact of COVID-19 on select health services in Ghana

University of Ghana School of Public Health

Disruption in DTP3 vaccine doses in Ghana, 2020

IHME

Based on an analysis from the Institute for Health Metrics and Evaluation of administrative data, the figure above shows the ratio of the monthly number of doses of DTP3 vaccine (third dose of diphtheria, tetanus, and pertussis vaccine) given to children younger than one year old in 2020 as it compares with the same month in 2019. A value of 1 represents no change and values less than 1 indicate delivery disruption.

In March and April 2020, there was a substantial decline in the number of children who received received the third dose of DTP3 vaccine in Ghana. However, this ratio bounced back in May 2020 and Ghana was able to maintain DPT3 coverage throughout the rest of 2020.

Nutritionist Charles Jaween teaches a group of student dieticians at the University of Ghana Medical Center in Accra, Ghana, on June 23, 2022.
Nutritionist Charles Jaween teaches a group of student dieticians at the University of Ghana Medical Center in Accra, Ghana, on June 23, 2022.
Credit: Nana Kofi Acquah. Copyright: © Gates Ventures, LLC.

During the COVID-19 pandemic, the emergency preparedness and response plans implemented by the Ghana health system—many of which were adapted from preexisting emergency plans for other infectious diseases—likely minimized COVID-19 infection in health facilities. Key informants believed they also strengthened existing health structures, logistics, and human resource capacities.

To provide unrestricted access to essential and routine health services even during pandemic lockdowns, officials in Ghana did not close any health facilities. Instead, they conducted extensive screening for COVID-19 at all facility entrances (including quick antigen testing when those tests became available) to minimize the risk of patient infection. Patients with positive antigen tests were further screened with PCR tests before they were allowed to enter.

The Ministry of Health and the Ghana Health Service implemented other service delivery adaptations to reverse interruptions to essential health service delivery, including:

  • At-home case management: Patients with mild or non-life-threatening conditions received advice and education from community health workers on how to manage those conditions at home instead of at health facilities during peak phases of the pandemic.
  • Appointment systems: Frontline workers in health facilities adopted an appointment system, which helped facilities run as efficiently as possible even when they were understaffed and despite the additional tasks and responsibilities associated with the COVID-19 emergency. The appointment system assigned less severely ill patients to days of the week when health workers were less busy and rescheduled elective surgeries (once they had resumed) to enable health workers to focus their attention on patients with new or severe COVID-19 cases.
  • Home visits: Community health workers provided simple and routine essential health services (including antenatal care and routine vaccinations) in patients’ homes, so they could still receive those key services without risking infection in health facilities.
  • Telehealth: Many key informants considered telemedicine (via telephone, video conferencing, mobile health platforms such as Omni, and apps such as COVID Connect) to be Ghana’s most important pandemic service delivery innovation. They used these tools for patient screening, care, and follow-up as well as collaboration with (and continuing education for) other health service providers.

With support from WHO, the Ministry of Health and Ghana Health Service implemented targeted measures to ensure the continuity of key services such as malaria treatment, services for people living with HIV and tuberculosis, routine immunization services, and maternal and child health care.95

PPE was made available for health workers providing malaria treatment and prevention services, such as indoor mosquito spraying, during the COVID-19 pandemic. Health officials also adjusted ordering logistics to preserve stocks of artemisinin-based combination therapy, rapid diagnostic tests for malaria, and other essential supplies.95

Ghanaian health officials developed guidelines for the care of people living with HIV in the COVID-19 context, supporting the use of technology such as telemedicine and other innovative approaches for training and testing. As a result of these interventions, Ghana met its 2020 targets for newly diagnosed persons and current treatment.97

 

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WHO further supported efforts to sustain essential health services during COVID-19 to ensure the delivery of routine immunizations by establishing sustained coordination mechanisms between Ghanaian health officials and international partners, developing and disseminating guidelines for the continuity of child health services (including Expanded Programme on Immunization services), supplying PPE, developing recovery plans, and other key activities in partnership with the Ministry of Health.

Nurse Daniel Mireku Akomeah dresses a patients wounds as Doctors, Evans Akomea and Peter Kwamina McCarthy look on at the University of Ghana Medical Center in Accra, Ghana, on June 24, 2022. Credit: Nana Kofi Acquah.
Nurse Daniel Mireku Akomeah dresses a patients wounds as Doctors, Evans Akomea and Peter Kwamina McCarthy look on at the University of Ghana Medical Center in Accra, Ghana, on June 24, 2022. Credit: Nana Kofi Acquah.
Copyright: © Gates Ventures, LLC.

To maintain essential health service delivery alongside the delivery of critical care for COVID-19 patients, the government of Ghana engaged the services of 50,970 permanent and 7,221 temporary health care workers in 2020.76 The aim of this staffing increase was to improve access to and quality of care across Ghana, especially in rural parts of the country that are typically underserved.

 

Number of healthcare workers recruited in 2020

MoH 2021

 

Health facilities in Ghana also implemented the following key human-resource innovations.

  • Shift systems for frontline health workers: Key informants reported that frontline health workers avoided congestion and crowding at health facilities and minimized COVID-19 transmission by running a staff rotation or shift system that allowed only a few nurses in a facility at a time.
  • Health worker training on infection prevention and control: Health workers at all levels of the system received extensive training on how to prevent and control infection and use PPE, communicate with patients about self-isolation and treatment options, implement the 3Ts strategy, and draw samples from suspected COVID-19 patients. The training was conducted remotely and in person at national, regional, district, and community levels by staff from the Ministry of Health and teaching hospitals, and targeted medical doctors, laboratory technicians, nurses, disease control officers, pharmacists, and public health experts.
Community health nurses Priscilla Osei and Juliana Akumatey visit homes, schools, bus stations, and wherever they can find people to vaccinate against COVID-19 on June 3, 2022.
Community health nurses Priscilla Osei and Juliana Akumatey visit homes, schools, bus stations, and wherever they can find people to vaccinate against COVID-19 on June 3, 2022.
Credit: Nana Kofi Acquah. Copyright: © Gates Ventures, LLC.
  • Health worker incentives: Government officials provided free commuter buses for health workers in some communities. Many frontline health workers also received psychosocial support and donations, including PPE, from nongovernmental organizations. Some health facilities engaged psychologists that health care providers could call on for assistance. Health officials also offered financial incentives to frontline health workers, which also boosted their enthusiasm. According to interviews with key informants, health workers were motivated to work in large part by the positive results they saw in their communities as a result of their efforts. Some health workers who were not initially classified as frontline health workers even volunteered their services, augmenting staff rosters and bolstering the capacity of the health workforce considerably.
Pharmacist Philomena Osei Agyemang sees a patient at the pharmacy in the University of Ghana Medical School in Accra, Ghana, on June 24, 2022. Credit: Nana Kofi Acquah.
Pharmacist Philomena Osei Agyemang sees a patient at the pharmacy in the University of Ghana Medical School in Accra, Ghana, on June 24, 2022. Credit: Nana Kofi Acquah.
Copyright: © Gates Ventures, LLC.

After Ghana recorded its first COVID-19 cases in March 2020, officials established a case management team that included the presidential advisor on health; the director of public health; infectious disease experts; doctors, nurses, and laboratory technicians; and representatives from the Ghana Health Service and the Ministry of Health. This team advised health facilities on setting up triage stations and informed the government on specific isolation and treatment center needs in each of the country’s 16 regions.

In June 2020, the case management team organized technical support visits—each of which included 10 experts from the Ghana Health Service/Ministry of Health and two from the World Health Organization—to assess each of those isolation and treatment centers. In all, they visited 75 COVID-19 treatment centers and 23 isolation centers, with a total of 2,068 beds. The technical support assessors concluded that this number was inadequate, as was the country’s capacity to manage severe and critical cases of COVID-19. The team counted just 87 intensive care beds in Ghana, less than half of which were designated for COVID-19 case management—not enough to manage the pandemic while providing other acute health care services at the same time. Regional-level facilities also had limited human resources and supplies, including ventilators.96

In response to this assessment, the government of Ghana and the Ghana COVID-19 Private Sector Fund commissioned and built the new 100-bed Ghana Infectious Disease Centre in Accra in just 100 days.97,98 Officials also secured US$100 million from the Ghana Investment Infrastructure Fund to build 111 health facilities in underserved regions of the country in 12 months: 101 new 100-bed district hospitals, 7 new regional hospitals, and 3 infectious disease centers.99 As of December 2021, these facilities had not been completed.

With private-sector collaboration, Ghana obtained other materials and infrastructure necessary for its pandemic response. According to one key informant, the country’s president worked with dozens of private pharmaceutical companies to accelerate the production of hand sanitizers. Another pointed out that private companies had donated key equipment such as ventilators, suction machines, and oxygen concentrators to health facilities—cooperation that was unprecedented before the COVID-19 emergency.

Regional breakdown of Ghana's health infrastructure, April 2020

MoH 2020

 

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However, according to key informants, logistical challenges remained. Demand for equipment sometimes exceeded the supply—for instance, some health facilities had only a single ventilator and multiple patients who needed it at one time. Some laboratories did not have the tools they needed, such as swabs to take patient samples; in other facilities, patients needed to buy their own drugs. Pharmacists found that border closures prevented them from importing essential medications.

The COVID-19 pandemic exposed geographic inequalities in Ghana’s health infrastructure. One February–March 2020 survey found that only 6 of the 16 regions in Ghana had functioning intensive care units, and most of the country’s intensive care beds were found in the Greater Accra, Ashanti, and Northern regions.100

 

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Patient-level measures

At the beginning of the COVID-19 pandemic, Ghanaian officials established a two-week quarantine for all international visitors. Private-sector partners provided all quarantine and isolation facilities, which included churches, hotels, hostels, and convention centers.8

To help mitigate inequities in access to care across Ghana, the country’s Ministry of Health released standardized treatment guidelines for COVID-19 in June 2020101along with strategies to maintain essential health service delivery.
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