Why is Ghana an Exemplar?

Key Points 

• During the Exemplars study period from 2000 to 2018, and especially after energy companies discovered the offshore Jubilee oilfield in 2007, Ghana’s economy expanded rapidly. 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.
• The government actively took steps to raise revenues for health, which enabled increased spending. Health spending per capita increased from US$36 in 2000 to US$76 in 2019. Government spending on health as a share of total health expenditure grew from 31% in 2000 to 40% in 2019. During that same period, out-of-pocket spending decreased from half of Ghana’s total share of health expenditure to just over one-third. The investments Ghana made in its health system prioritized improvements in primary health care (PHC) coverage: its universal health care effective coverage index improved from 24% in 2000 to 45% in 2019. This improvement in service coverage has been associated with improvements in population health outcomes. Under-five child mortality declined from 100 to 44 deaths per 1,000 live births between 2000 and 2021, a reduction of about 40%. The maternal mortality ratio also declined, from 484 to 308 per 100,000 live births between 2000 and 2017, a 36% reduction.
• Although Ghana’s economy has grown, the poverty rate has remained high—almost one-quarter of the population was poor in 2017—and the need for social services like health care is significant. Consequently, Ghana aimed to improve coverage equitably by increasing access to PHC nationwide—for example, by investing in a comprehensive National Health Insurance Scheme (NHIS) and innovating ways to deliver key PHC services close to the communities where people live via the Community-Based Health Planning and Services (CHPS) intervention. These interventions reduced coverage gaps between the poorest and richest population groups. It increased coverage for the lowest quintile by 25% and reduced inequality in coverage between the poorest and richest quintiles by 17% between 1998 and 2017.

Improving health system efficiency in Ghana

Charting a country’s performance on the universal health coverage (UHC) effective coverage index against the amount it spends on health care (measured by total health expenditure) over time is one way to measure health system efficiency. The effective coverage index is a composite measure of primary health system performance reflecting service coverage across a range of health services—including prevention, promotion, treatment, rehabilitation, and palliative care—and across the life course; it also reflects the need for health services, the use of health services, and the quality of health services.^12,13

We selected Exemplar countries by benchmarking country performance against an optimal possible output—the “frontier”—which is the modeled, maximum effective coverage a country could attain at a given level of spending, in addition to other factors. This method of econometric analysis demonstrates how close a country is to the maximum possible output it could achieve with its money, by charting its health system’s improvement over time. This optimal production framing implies an underlying assumption about the relationship between investment and output—there is only so much health a country can achieve at a given level of spending. Once a country has hit the frontier, it must invest more resources if it seeks to achieve greater gains in health system performance.

As Figure 1 shows, Ghana had a rising effective coverage index compared with its total health expenditure per capita. The country improved its UHC effective coverage from an index score (0–100) of about 40 in 2000 to 49 in 2018.

Analysis of PHC indicator data shows that with these efficiency improvements, Ghana has improved the overall coverage of the population with PHC services such as immunization and antenatal care visits for pregnant women (Figure 2). 

Ghana has simultaneously increased its domestic spending on health. Health spending per capita increased from US$36 in 2000 to US$76 in 2019, and government spending on health as a share of total health expenditure grew from 31% in 2000 to 40% in 2019. Estimates on how much of that total expenditure goes to PHC ranges from 45% to 79%.^14,15

Improvements in population health outcomes have accompanied these improvements in service coverage. Ghana has also made great strides on key health outcome indicators such as maternal and child mortality (Figure 3). Under-five child mortality declined from 101 to 56 deaths per 1,000 live births between 2000 and 2017, a reduction of about 44%. The maternal mortality ratio also declined, from 499 to 274 per 100,000 live births between 2000 and 2017, a 45% reduction (Figure 3). As Figure 4 shows, the country has also made significant progress in reducing overall population disability-adjusted life years (DALYs).

Improving health system equity in Ghana

During the Exemplars study period from 2000 to 2018, Ghana adopted a series of reforms that were specifically aimed at reducing health inequalities. Interventions like the National Health Insurance Scheme made PHC services more affordable to all Ghanaians.

Other health system interventions worked together to produce more equitable outputs and outcomes. Innovations like the Community Health and Family Planning Project brought PHC services closer to geographically isolated communities.

Evidence shows that these efforts to improve health system equity reduced coverage gaps between the poorest and richest population groups. For example, as Figure 5 shows, between 1996 and 2020, Ghana increased PHC coverage for the lowest quintile by 27% and reduced inequality in coverage between poorest and richest wealth quintiles by 11%.

Financial risk protection policies safeguard individuals from health care costs that may impoverish them, remove barriers to PHC access, and increase health care utilization. In Ghana, interventions like the National Health Insurance Scheme, free maternity care policies, and the Livelihood Empowerment Against Poverty (LEAP) program aimed to make it easier and more affordable for people nationwide—and especially the country’s poorest and most vulnerable citizens—to obtain key health services.

Earlier policies in Ghana implemented a “cash-and-carry” system in which individuals paid for services prior to receiving care. However, this worsened access to care for the poor, and it was abolished at the turn of the 21st century. As Figure 6 shows, out-of -pocket spending as a proportion of current health expenditure has dropped considerably, from more than 50% in 2000 to less than 30% in 2020.

During the same period, as Figure 7 shows, researchers also recorded a reduction in catastrophic spending, as measured by the proportion of household expenditures on health greater than 10% of total household expenditure or income (Sustainable Development Goal 3.8.2).¹⁹ The threat of catastrophic health spending weighs most heavily on the poorest people with the least money to spare. Between 1991 and 2016, the number of Ghanaian households in this category fell by nearly 80%.