Universal health coverage for sexual and

reproductive health in Ghana

Evidence brief

Evidence and policy implications

Key messages
` This brief highlights evidence from a case study of Ghana that critically examines the progress
in national measures, experiences and implementation to achieve universal access to various
sexual and reproductive health (SRH) services. Three tracers of this are discussed: pregnancy
and delivery, gender-based violence (GBV), and safe abortion/post-abortion care. Although
Ghana has made considerable progress towards universal health coverage (UHC), there are
gaps in prioritization, resource allocation and access in these areas.

` Maternal health has always been considered a high priority by the Government of Ghana,
with pregnancy and safe delivery services provided through both public and private sectors
and covered under the free maternal health care programme. However, issues remain, such
as with the distance to facilities, social/cultural factors and the quality of maternal health care
services.

` To fulfil its international obligations, Ghana has made significant progress towards protecting
the women and children who are worst affected by GBV. Progress is, however, hampered
by a lack of reliable GBV data, poor knowledge and/or training of health care workers and
inadequate coordination among state agencies dealing with different aspects of GBV.

` Prioritization of, and access to safe abortion and post-abortion care is challenged by
political will plus wider contextual factors. Key policy implications include: using evidence-
based political prioritization; reorganizing scopes of practice to expand access to critical
SRH services and optimize service delivery; establishing legislative mandates and a clear
governance and accountability framework for SRH; and dedicating resources to support and
sustain implementation.

Introduction even more pronounced in low-income countries where

Many countries have committed to investing in SRH
over the last few years. However, progress has been
slow due to weak political commitment and leadership,
inadequate resources, cultural and legal barriers, and
gender and health systems challenges (1,2). This is
funding for SRH services, which is largely donor-driven,
is dwindling (3). Responsibility for improving SRH
ultimately lies with national leaders, who are striving
to develop long-term strategies to ensure sustainable
access to comprehensive SRH services (4–6). In Ghana,
access to SRH services is a fundamental human right
2 Universal health coverage for sexual and reproductive health in Ghana
enshrined in the 1992 Constitution. Since the early
1990s, Ghana has taken steps to ensure that it is a high
priority by implementing interventions, policies, laws
and programmes aimed at expanding access to SRH
services. Key among them are:
• the Community-based Health Planning and Services
programme
• the free maternal and child health policy under the
National Health Insurance Scheme
• the Domestic Violence Act 2007
• the National Gender and Children Policy.
For decades, maternal and child health has remained a
higher priority for the Government of Ghana than other
SRH services. Some achievements in the protection
of women’s rights include the criminalization of
harmful traditional practices under the Criminal Code
(Amendment) Act 1994 and the passage of the Human
Trafficking Act in 2005. In spite of progress towards
universal access to the full range of SRH services
in Ghana, efforts are being impeded by structural,
administrative and stakeholder processes in relation to
the prioritization, planning and implementation of SRH
programmes and activities in the country.
About this evidence brief
The aim of integrating SRH services into UHC is
to ensure individuals, including those who are
disadvantaged and marginalized, receive quality,
rights-based, non-discriminatory services without
experiencing financial hardship. This evidence brief
provides an understanding of Ghana’s progress
towards integrating SRH services into UHC. Particular
consideration is given to the political, socioeconomic
and cultural contexts that have influenced these
services, and how these factors have affected
population and service coverage and financial risk.
This evidence brief arises from an in-depth study
on Ghana involving key stakeholders, including
government agencies, multilateral organizations and
nongovernmental organizations.
Findings from the government’s
approach to integrating SRH into UHC
Maternal health: a national emergency
Maternal health has always been considered a
high-priority issue by the Government of Ghana (7).
Several internationally recommended interventions
(such as the Universal Declaration of Human Rights
and the International Conference on Population
and Development) and local initiatives have been
implemented by the Ministry of Health, the Ghana
Health Service and partners to promote maternal health
(8,9). Although maternal mortality remains high, it has
reduced significantly in the past three decades, from
740 per 100 000 live births in 1990 to 451 in 2008 (10).
In 2017 there were 310 maternal deaths per 100 000
live births (11). Despite this, Ghana failed to meet
Millennium Development Goals 4 and 5 regarding
reduction in child and maternal mortality by the end of
2015 (12). In response, the Government of Ghana has
instituted a number of innovative interventions over
the past two decades to address the high maternal
mortality, including (13):
• the Safe Motherhood Programme
• Community-based Health Planning and Services
• User Fees Exemption for Delivery
• National Health Insurance Scheme
• the Millennium Development Goal 5 acceleration
framework.
Maternal mortality was declared a national emergency
by the Minister of Health and a maternal mortality
conference was held in July 2008, attended by
representatives from Ghana and overseas (14). This led
in that year to the introduction of the free maternal
health care policy, which was largely seen as a
politically driven initiative (10). Stakeholders included
individuals from the Ministry of Health, the Ghana
Health Service, the Christian Health Association of
Ghana and the National Health Insurance Scheme,
who worked together to produce these guidelines
(15). The guidelines specified who was eligible for free
health care (all pregnant women and newborns up
to 3-months old) and details of the benefits package
(that is, all health services normally provided within
the National Health Insurance Scheme package falling
 Universal health coverage for sexual and reproductive health in Ghana
within the year, beginning from the presentation of a
pregnant woman to a health care facility (10)). Since
2008, this policy has contributed to an increase in
National Health Insurance Scheme enrolment and
improvement in health care delivery (16,17).
The Safe Motherhood Programme arose from a
task force, supported and operationalized by the
government, to reduce morbidity and mortality, and to
improve the availability and quality of maternal health
services. The broad initiative included programmes
addressing demand and supply interventions, such as
training health care workers and improving facilities
(18). For example, increased training facilities led to a
greater level of enrolment of midwives, enabling the
Ministry of Health to place more trained midwives in
Community-based Health Planning and Services zones,
which have the lowest level of health care provision at
the community level.
Despite these policies, implementation and health
outcomes have been mixed. There remain some
significant challenges to ensuring universal access to
maternal health care. For instance, according to the
most recent maternal health survey conducted in
Ghana, there is a disparity in the number of women
receiving at least four antenatal care visits, between
those who live rurally (83%) and those living in urban
areas (92%). The level of skilled attendance at birth is
also lower (60%) in rural areas compared with urban
areas (90%). Also, nearly all pregnant women from the
most wealthy households (98%) made at least four
antenatal care visits, whereas only 76% of pregnant
women from the poorest households did so. Only 47%
of deliveries in the poorest households had a skilled
attendant at birth, compared with 97% of deliveries in
the richest households. Furthermore, 29% of newborns
in the richest households receive postnatal care within
two days of birth, but only 25% among the poorest
households do (19).
Distance from, and journey time to the nearest facility
are perceived as barriers to seeking care. Infrastructure,
laboratory tests, drugs and supplies, equipment, water,
electricity and emergency transport have also been
cited as either being inadequate or unavailable in many
of the lower-level facilities (Community-Based Health
Planning and Services compounds) (16).
While the direct cost of service delivery is nil, there
remain some indirect costs related to antenatal
care and delivery, which limit the use of hospital-
3
based midwifery and obstetric care. Emergency
referral has been recognized as a challenge. To
address this, the local government initiative, “One
constituency 1m USD” has provided each of the 275
constituencies in Ghana with an ambulance. In spite
of an increase in skilled health care workers, supply of
equipment, improved logistics, staff accommodation,
transportation and ambulance services, poor quality
of care continues to persist. Women are also reluctant
to give birth in health facilities due to the poor quality
of care experienced in the past at health facilities in
Ghana (17).
Gender-based violence
GBV has received some attention, but not to the same
degree as maternal health. The media, civil society and
nongovernmental organizations raising awareness of
GBV have been vociferous in highlighting the issue
and ensuring that offenders are brought to account
by the law. The Ministry of Gender, Children and
Social Protection is responsible for coordinating and
ensuring gender equality and for the social protection
and development (physical, mental and educational)
of children, vulnerable and excluded people, and
people living with disability. Steps have been taken to
safeguard citizens’ constitutionally protected rights to
live free from violence. For example, in 1998, the Ghana
Police Service established a women and juveniles unit,
which resulted in increased reports of violence against
both women and children. In 2007, the Domestic
Violence Act (Act 732) was passed.
GBV is not prioritized as highly as other components
of SRH, despite these legal provisions. Socioeconomic
inequalities and gender norms continue to create
an atmosphere in which GBV is tolerated. Female
(and male) victims are unlikely to report incidents of
GBV, and there is little public outcry, and therefore
less incentive for policy-makers and programmers to
prioritize the issue. There is also a lack of quality data
on the gravity of the situation, and perpetrators are
not being brought to account by law enforcement
agencies (20).
4 Universal health coverage for sexual and reproductive health in Ghana
Safe abortion
Although Ghana has relatively broad abortion laws,
complications as a result of unsafe abortions are the
leading cause of maternal mortality for young women
(under 19 years) and the second leading cause of
maternal mortality for all women of reproductive
age (21,22). This is despite the aim for safe abortion,
performed by a qualified health care provider, being
part of the reproductive health strategy since 2003.
Abortion is currently a criminal offence regulated by
Section 58 of the Criminal Code (Act 646) (23) but
Section 2 of this law states that:1
“It is not an offence under subsection (1) of
this section if an abortion or a miscarriage is
caused in any of the following circumstances
by a registered medical practitioner specialising
in gynaecology or any other registered medical
practitioner in a Government hospital or in a
private hospital or clinic registered under the
Private Hospitals and Maternity Homes Act, 1958
(No. 9) or in a place approved for the purpose by
legislative instrument made by the Secretary.”
1 Section 58 – Abortion or Miscarriage.
(1) Subject to the provisions of subsection (2) of this section –
(a) any woman who with intent to cause abortion or miscarriage
administers to herself or consents to be administered to her any
poison, drug or other noxious thing or uses any instrument or
other means whatsoever; or (b) any person who – (i) administers
to a woman any poison, drug or other noxious thing or uses any
instrument or any other means whatsoever with the intent to
cause abortion or miscarriage, whether or not that the woman is
pregnant or has given her consent; (ii) induces a woman to cause
or consent to causing abortion or miscarriage; (iii) aids and abets
a woman to cause abortion or miscarriage; (iv) attempts to cause
abortion or miscarriage; or (v) supplies or procures any poison,
drug, instrument or other thing knowing that it is intended to be
used or employed to cause abortion or miscarriage, shall be guilty
of an offence and liable on conviction to imprisonment for a term
not exceeding five years.
(2) It is not an offence under subsection (1) of this section if
an abortion or a miscarriage is caused in any of the following
circumstances by a registered medical practitioner specialising
in gynaecology or any other registered medical practitioner in a
Government hospital or in a private hospital or clinic registered
under the Private Hospitals and Maternity Homes Act, 1958 (No. 9)
or in a place approved for the purpose by legislative instrument
made by the Secretary:
(a) where the pregnancy is the result of rape, defilement of
a female idiot or incest and the abortion or miscarriage is
requested by the victim or her next of kin or the person in loco
parentis, if she lacks the capacity to make such request; (b) where
the continuance of the pregnancy would involve risk to the life
of the pregnant woman or injury to her physical or mental health
and such woman consents to it or if she lacks the capacity to
give such consent it is given on her behalf by her next of kin or
the person in loco parentis; or (c) where there is substantial risk
that if the child were born, it may suffer from, or later develop, a
serious physical abnormality or disease.
Those circumstances include pregnancies resulting from
rape, those that would cause injury to the woman or
fetus malformation.
The Ghana Health Service promotes post-abortion
care within its facilities, through the development
of guidelines and policies built into the country’s
reproductive health framework. In 2003, reproductive
health policies and guidelines explicitly stated that
comprehensive abortion care should be provided by
trained health care professionals with midwifery skills
(that is, midwives and medical assistants). To ensure that
legal abortions are provided safely, the Ghana Health
Service and Ministry of Health developed protocols for
the provision of safe abortion. These guidelines were
adopted in 2006 and:
• outlined the components of comprehensive
abortion care, including counselling and the
provision of contraceptives;
• defined mental health conditions that could qualify
a patient for an abortion;
• called for expansion of the provider base by
authorizing midwives and nurses with midwifery
skills to perform first-trimester procedures.
The comprehensive abortion care policy was revised
in 2012 (24) to include task-sharing for abortion
care services at various levels of the health system,
including the community, sub-district, district, regional
and teaching hospitals. Although Ghana has made
significant strides in expanding the cadres of providers
for abortion care, ensuring access to services is still a
challenge, as midwives are not present in most primary
care facilities. In addition, abortion services are not
covered under the National Health Insurance Scheme,
and there is no regulation of fees for such services,
which can often be too high for care seekers.
Medical abortion is increasingly considered as an
alternative to surgical abortion in Ghana (25) and this
is reflected in the latest “Comprehensive abortion care
services standards and protocols” (26), which were
published and disseminated in 2021. The revised policy
also includes a pathway for self-care management
of medical abortion. Despite these impressive policy
developments, recent research suggests that there
is poor knowledge among women about the legal
grounds on which abortion is permitted (27). There
are also social, cultural and religious factors that delay
and affect the provision and demand for abortion care
services (28).
 Universal health coverage for sexual and reproductive health in Ghana
Policy Implications
Ghana has made substantial progress in the integration
of SRH services into UHC. However, critical challenges
remain, including: inadequate funding, non-inclusion of
comprehensive SRH services within the health benefits
package and hidden/indirect charges for pregnancy and
delivery services. Other issues include poor supervision,
maldistribution of logistics and health personnel (29),
fragmentation of support services for GBV victims
across agencies, and sociocultural/religious attitudes
affecting SRH service delivery and utilization (28).
These issues are being addressed by the Government
of Ghana at a policy level; the recent National Health
Strategic Plan is committed to “resilient health systems”
with high-quality services, irrespective of the patient’s
ability to pay (9). Also, the latest reproductive, maternal,
newborn, child, adolescent health and nutrition plan
centres particularly on increasing access to primary
health services (30).
Actions at policy level
• Improve stakeholder participation in policy
formulation and implementation: Create an
enabling environment for the participation of
communities, including marginalized and vulnerable
groups, by regularly evaluating policy dialogue
mechanisms. Communities should be included in
local health governance, community engagement
and monitoring to allow greater involvement.
• Use evidence-based political prioritization: A
concerted effort is required to highlight issues of
poor access to SRH services, using the available
evidence. Education and training institutions need
to scale up sustainable training of the health care
workforce with competencies in SRH to respond
to current and future needs. This will require the
development of evidence-based workforce policies
and strategies.
5
• Reorganize scopes of practice to expand
access to critical SRH services and optimize
service delivery: The capacity of national
regulatory authorities ought to be strengthened
to regulate health professional practice, in both
the public and private sectors, including the
development of professional bodies and models
of care that advance comprehensive integrated
SRH services.
• Establish legislative mandates and a clear
governance and accountability framework
for SRH and dedicate resources to support and
sustain implementation: Annual and semi-annual
national review meetings of stakeholders are
necessary to improve SRH programmes, and to
increase awareness of concurrent activities, the
milestones reached and any gaps where attention
may be needed.
• Develop a national master plan for SRH
integration within UHC: The government needs
to make a concerted effort to address financial,
logistical and health worker shortages and
maldistribution through a rigorous planning
process. This may be best achieved through
a national master plan for SRH integration
within UHC, which could address issues such as
expanding the health benefit package and long-
term funding strategies.
• Further the research into the implementation
of comprehensive abortion policy: Do targeted
research to understand the recent abortion policy
implementation, implications for service delivery,
providers’ perceptions (and receptivity) and users’
experiences.
• Commit to fostering strong and resilient health
systems: Strengthen the health system at its most
critical point of service delivery in line with the
principles of primary health care.
6 Universal health coverage for sexual and reproductive health in Ghana
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