Context

Geography and culture

With more than 34 million people, Ghana is the second most populous country in West Africa.¹ (Nigeria is first.) Its relatively thriving economy sets it apart in the region, as does its status as the first country in sub-Saharan Africa to gain independence from a European colonial power in 1957.²

More than 70% of Ghana’s population is Christian and 20% are Muslim.³ Ghana is ethnically diverse, with dozens of ethnic groups and subgroups across seven main categories (Akan, Mole Dagbani, Ewe, Ga-Dangme, Gurma, Guan, and Grusi).⁴ English is the official language, but more than 80 other languages are also spoken. Its capital is the coastal city of Accra. In 2023, nearly 60% of Ghana’s population lived in urban areas.⁵

Ghana has a tropical climate that varies widely. Bordered on the south by the Gulf of Guinea and subject to West African monsoon winds, its coast has both a rainy and a semiarid region. The south has two rainy seasons, while the north is hotter and drier. More than half of the country’s land area is dedicated to rain-fed agriculture, and most is tended by smallholder farmers.⁶

In decades pre-2024, rainfall has declined, even as extreme rainfall events have increased.⁷ Climate change has also exposed Ghana to floods, landslides, coastal erosion, rising sea levels, and storm surges. Because it depends on rainfall for irrigation, Ghana’s agricultural economy is particularly vulnerable to erratic precipitation and other effects of climate change.⁶

Politics

In 1957, after decades of struggle, the British Gold Coast colony became the independent nation of Ghana. Kwame Nkrumah, its prime minister, was a socialist and visionary pan-Africanist who aimed to build in Ghana the ideal post-colonial, post-capitalist state.⁸ Nkrumah was also an authoritarian, and he declared himself president for life in 1964. He was ousted by a police-military coup in 1966.

Subsequently, Ghana was ruled by military governments punctuated by short periods of civilian democracy. Ghana’s Second Republic civilian government was in power from 1969 until a military coup in 1972, and the Third Republic from 1979 until 1981.⁹ In 1981, a group of soldiers led by military commander Jerry John Rawlings toppled the republic and established a new government, the Provisional National Defense Council (PNDC). The PNDC ruled as a unitary government until 1992, when—in response to pressure from inside and outside Ghana—it drafted a constitution and allowed multiparty elections for the first time in 11 years. Ghana’s Fourth Republic was inaugurated in 1993.

Since 1993, Ghana has been a democracy in which two main political parties—the National Democratic Congress and the New Patriotic Party—compete for votes in part by responding to popular demands for key social services, especially health care.

Ghana’s government has exhibited strong performance in markers of human development, including health care, rising incomes, education, and gender outcomes. It is also one of the top performers in terms of economic growth in sub-Saharan Africa.¹¹

Economy

During the Exemplars study period, and especially after energy companies discovered the offshore Jubilee oil field in 2007, Ghana’s economy expanded rapidly.¹² In 1995, the World Bank classified Ghana as a low-income country. In 2024, it is a lower-middle-income country with the second largest economy in West Africa.^13,14

Consequently, Ghana’s gross domestic product (GDP) per capita increased considerably from US$235.40 in 2000 to US$2,238.20 in 2020.¹⁵ In spite of the country’s economic difficulties, its gross national income per capita is still higher than average for sub-Saharan Africa.¹⁶ The percentage of the population living on US$2.15 or less a day declined from 55% in 1998 to 25% in 2015.¹⁷ Remittances from Ghanaians who have emigrated to other countries contribute modestly to many households’ incomes and accounted for about 6% of Ghana’s GDP in 2022.¹⁸ Ghana’s tax revenue to GDP ratio is among the lowest in Africa.¹⁹

Ghana’s economy is enormously dependent on the export of mineral commodities, primarily gold and now oil, and cocoa.²⁰ This lopsided economy—for example, manufacturing comprises less than 10% of the country’s economic output—makes Ghana particularly vulnerable to the environmental, health, and economic effects of natural-resource extraction.²¹ For instance, Ghana’s carbon emissions increased 32.5% between 2005 and 2010 and 44.4% between 2010 and 2019.²² A 2023 environmental analysis showed that air pollution cost Ghana more than US$2 billion each year and accounted for approximately 16,000 early deaths annually.²³ Extractive economies also concentrate growth at the top of the economy. Between 2006 and 2013, Ghana’s per capita GDP grew by nearly 50%, but the number of people living below the poverty line fell by just 10%.

In particular, Ghana’s three agriculture-dependent northern regions, where the climate is not suitable for cocoa or other cash crops, have experienced high population growth without corresponding economic growth.²⁴ The majority of their population lives on less than US$1 per day.²⁵

Organization of Ghana’s health system

Ghana has a decentralized governance system for health. The Ministry of Health is the main governing body of the Ghana health system and is responsible for policymaking, national planning, coordination, and overseeing teaching and specialized hospitals.

In 2003, the Ministry of Health delegated service delivery to a new semiautonomous agency, the Ghana Health Service. The Ghana Health Service is responsible for health service delivery by ensuring accessible health services at the regional, district, subdistrict, and community levels.

Ghana has a three-tier health delivery system consisting of district (primary), regional (secondary), and national (tertiary) levels. PHC is delivered at the district level. The district health services are organized into three levels (Table 3):

• District level, which includes district hospitals that provide preventive, curative, and promotive health care services.
• Subdistrict health centers, clinics, and maternity homes, which serve as the first point of contact with the formal health system and provide basic preventive and curative services.
• Community-Based Health and Planning Services (CHPS), which provide preventive, promotive, and treatment of common/minor illnesses.

In 2011, the Health Institutions and Facilities Act²⁶ created the Health Facilities Regulatory Agency (HeFRA) to license both public and private health care facilities. HeFRA’s goal is to establish a uniform standard for the quality of care delivered by health facilities in Ghana; it also inspects and monitors health facilities for compliance.²⁷ Because it is an independent body applying a consistent set of quality criteria, it can be an enabler of health system success.

Networks of practice

In 2017, with support from the US Agency for International Development, Ghana began implementing a new initiative to accelerate progress toward achieving universal health coverage, by piloting a primary care provider network in two districts.²⁸ Key features of this network center around unifying individual facilities to goals that align with the health needs of a defined population. The group is jointly accountable for clinical and financial outcomes, as well as the quality of care for the population they are serving.²⁹ The success of this intervention led the country to scale the intervention nationally, and it is now referred to as Ghana’s Network of Practice. In 2021, 32 networks across six districts in the Volta Region and 23 districts in the Bono region were operational.²⁷ The government and external partners continue to collect data on the rollout and consider how to further strengthen the program—notably around how to implement a sustainable and effective payment mechanism and financing arrangement.³⁰

Health spending

Ghana is considered a sub-Saharan African economic success story. Indeed, between 1995 and 2020, Ghana’s GDP grew more than 984%; global GDP grew about 173% between 1995 and 2020, and lower-income countries as a group saw GDP growth of 461%.³¹ Notably, Ghana’s GDP growth was higher than its neighbors Cote d’Ivoire, Burkina Faso, and Togo—classified by the World Bank as lower-middle, low, and low-income countries, respectively—where GDP grew 473%, 645%, and 472%.

During the same period, Ghana’s total health expenditure increased from US$492 million to US$2.77 billion, an increase of roughly 463%. Meanwhile, health spending in Cote d’Ivoire, Burkina Faso, and Togo between 1995 and 2020 increased as follows:

• Cote d’Ivoire: 131% (from US$1.04 to US$2.40 billion)
• Burkina Faso: 590% (from US$187 million to US$1.29 billion)
• Togo: 456% (from US$103 to US$573 million)³²

In Ghana, potentially due to economic growth, government health spending as a percentage of Ghana’s total spending on health increased between 2000 and 2019 (from 31% to 40%), and the country’s reliance on out-of-pocket spending—which can lead to catastrophic spending on health for individuals and families—decreased from 50% of total per capita health expenditure to 37% during the same period.

Development assistance for health in Ghana fluctuated during this period, but Ghana now relies less on development assistance for health (DAH) than its neighbors. In 2019, DAH comprised 11% of Ghana’s total health expenditure, and per capita DAH in Ghana was US$10.32. In the same year, DAH comprised a greater proportion of its neighbors’ health spending, and their DAH was higher than Ghana’s on a per capita basis:

• Cote d’Ivoire: 20.18% of 2020 total health expenditure, US$17.78 DAH per capita
• Burkina Faso: 27.59% of 2020 total health expenditure, US$16.07 DAH per capita
• Togo: 32.96% of 2020 total health expenditure, US$23.03 DAH per capita

Figure 17 shows how sources of health spending in Ghana changed during the study period from 2000 to 2018.