Why was Ghana selected?

Executive summary

Starting in March 2020, officials in Ghana implemented a wide variety of interventions aimed at mitigating the effects of the COVID-19 pandemic on individuals and the health system. These early efforts focused on case identification via contact tracing, public health and social measures such as movement restrictions, strengthening the capacity of the health system to care for sick and infected people, and minimizing the pandemic’s effect on the country’s social and economic life.

At the same time, in Ghana as in most other countries around the world, responding to the COVID-19 pandemic resulted in substantial interruptions to the delivery of key essential health services such as routine vaccinations, maternal health care, and management of chronic diseases. Officials also implemented service delivery innovations aimed at mitigating these disruptions. Between March 2020 and December 2021, data show that initial declines in key essential health services indicators were reversed and essential health services were maintained, even during periods of lockdown.

How did we select the countries we studied?

Differences in testing, surveillance capacities,¹ and reporting criteria have made it difficult to quantify² and compare the impact of COVID-19 in countries around the world. Yet some countries were able to strengthen and sustain health system capacity, maintain essential health services, and target public health and social measures to mitigate the overall impact of the COVID-19 pandemic. Identifying the strategies, policies, and practices that enabled these successes can give us a better understanding of health system resilience, adaptive health policies, and emergency response strategies that could be applied to other countries and future infectious disease outbreaks.

To select positive outlier countries with transferable lessons for pandemic preparedness and health system resilience, we used data from March 2020 through the end of 2020 to identify countries with best-practice responses to the early phases of the pandemic. This snapshot in time does not account for subsequent waves of the pandemic, nor for the later availability of COVID-19 vaccines in the selected countries.

The six countries were selected by evaluating COVID-19 indicators (including age-standardized death rates, cases per million, and testing rates) and essential health services indicators (including disruption to routine immunization) after screening for the availability of high-quality data. After identifying potential Exemplar countries, we completed validation research including an examination of the COVID-19 epidemiological curve over time, testing policies and strategies, interventions to maintain essential health services, survey data, and interviews with local and regional health experts. The final six countries (Dominican Republic, Costa Rica, Sri Lanka, Thailand, Uganda, and Ghana) were selected after considering linguistic, demographic, and geographic diversity as well as government structure and data availability (see figure below).

For Ghana and the other five countries, we conducted a literature and policy review, key informant interviews, qualitative analysis, and quantitative analysis. We synthesized findings to develop key recommendations on health system resilience and pandemic preparedness. Through this country selection process we reviewed indicators through the end of 2020, but our research covers the time period at least through the end of 2021.

Key insights: Ghana

Several key interventions, summarized below and detailed in the following pages, contributed to Ghana emerging as a positive outlier in the COVID-19 response and the maintenance of essential health services.

Quick early action

After Ghana recorded its first case of COVID-19 on March 12, 2020, officials implemented a system for targeted contact tracing to find infected people and stop the community spread of the novel coronavirus. Officials referred to this approach as the “3T” strategy—test, trace, and treat—since health workers referred everyone who tested positive for COVID-19 to a health facility for isolation and treatment. As case counts increased, straining testing and laboratory capacity, the Ghana Health Service introduced pooled testing, a strategy that enabled health authorities to test large numbers of samples in a short time, even when laboratory capacity and key supplies such as equipment and reagents were limited.

Leadership and governance

Health officials in Ghana acted quickly to stop the spread of the novel coronavirus using tools and systems they already had. For example, the country’s District Health Information Management System (DHIMS) made it possible to share crucial data quickly with officials, health workers, and the public. The Surveillance Outbreak and Response Management and Analysis System (SORMAS), developed in Nigeria and adapted for the Ghanaian context, enabled officials to track COVID-19 cases in real time and adjust mitigation strategies accordingly. The data helped inform authorities’ decisions to implement public health and social measures such as border and school closures and temporary lockdowns. It also enabled easier distribution of key resources including personal protective equipment (PPE), hand sanitizer, and face masks.

Community engagement

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. 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.

From the beginning of the COVID-19 pandemic, the Ghana Health Service used mass media, including social media, to communicate with the public about preventive measures and public health protocols. Regular presidential addresses, ministerial press briefings, and government websites reinforced this official messaging, which was coordinated by a COVID-19 task force.

Essential health services maintenance

To continue delivering key essential and routine health services—while implementing public health and social measures to control the spread of COVID-19—Ghana’s health facilities stayed open from March 2020 on, while screening all patients for COVID-19. Service delivery adaptations aimed to strengthen the capacity of health workers and reduce transmission of COVID-19 in health facilities. Adaptations included the use of drones to deliver medical supplies and test samples (minimizing contact between health workers and others), health facility use of appointment systems that enabled the efficient deployment of frontline health workers (by rescheduling elective surgeries and assigning less severely ill patients to days of the week where health workers were less busy), and community health workers delivering routine essential health services via home visits.

Challenges

As in most other countries around the world, barriers to Ghana’s COVID-19 response—and particularly to the maintenance of essential health services—persisted through the end of the study period in December 2021.

Key informants pointed to four key challenges: fear, stigma, financial obstacles, and health worker burnout.

• Fear: In 2020 and 2021, frontline health workers and patients alike worried about contracting COVID-19 in health facilities. As a result, some patients avoided health facilities altogether, which was associated with an initial decline in health service utilization. It may also have kept patients from receiving tests or treatment for COVID-19 infection.
• Stigma: Similarly, surveys found that COVID-19 infection was so stigmatized that many infected people were reluctant to disclose their status. This stigma may have also kept patients from testing for and treating the pandemic pathogen.
• Financial obstacles: Some study participants reported staying away from health facilities during the early part of the pandemic because they did not want to pay for COVID-19 tests or treatment. (This problem may have been exacerbated by widespread job instability during that same period.) Health care workers also lacked sufficient PPE, in part because the health system lacked the resources to pay for them, which prevented many from carrying out their duties comfortably and safely.
• Health worker burnout: In Ghana as elsewhere, the COVID-19 pandemic placed enormous physical and psychological strains on frontline health workers. PPE shortages, inadequate psychological support, and a lack of financial or other incentives to stay on the job contributed to health worker burnout and made it difficult for them to feel safe and supported at work. In addition, the stigma associated with the novel coronavirus sometimes attached to them as well: some communities reported widespread discrimination against health workers by people who feared they would spread the virus.