Health systems are considered one of the largest sectors of the world’s economy and among the most important determinants of community development and social welfare [1]. In recent times, there has been an increased emphasis on improving the performance of health systems, especially in low and middle-income countries (LMICs) to meet the health needs of the people. Policy makers and development experts have realized that strong health systems are key to achieving and sustaining health gains [1, 2]. Increased attention to improving the performance of health systems has also been stimulated by the United Nations Sustainable Development Agenda that calls for attaining health related targets, including improving maternal health, reducing child mortality, achieving universal health coverage (UHC), and preventing and controlling a number of diseases that have greater bearings on population health by the year 2030 [3]. There is now growing consensus that without strong health systems, achieving and sustaining the health-related components of the Sustainable Development Goals (SDGs) will be difficult if not impossible [4].
Assessing the performance of health systems through quantitative and qualitative methods is recognized as an effective approach to strengthening national health systems [5]. Health system performance assessment (HSPA) is a tool for gathering information about the functioning of a health system to inform policy decisions, monitor progress towards improved health, and to identify best practices. Measuring the performance of a health system is considered an essential requirement in creating systems that are resilient, responsive, efficient, equitable, patient-focused, accessible and sustainable [5]. Further, HSPA is viewed as a step towards promoting transparency and accountability in healthcare services delivery. As a result, HSPA has now emerged as one of the priority areas of health systems research [6].
Measuring and improving the performance of a health system is not new. For instance, in the 1860s, Florence Nightingale pioneered systematic collection, analysis and dissemination of hospital data to understand and improve hospital performance []7]. However, the first attempt to systematically measure the performance of health systems in a rigorous manner was based on the work of the World Health Organization (WHO), through its publication of the “World Health Report 2000”, where the performance of health systems in WHO member states was comprehensively assessed [8, 9].
Many high-income countries (HICs) have institutionalized HSPA as an integral component of their respective health systems [6, 10, 11]. However, few studies on HSPA have been documented in LMICs [12–15]. Examples of these few studies in LMICs include an analysis of district level HSPA within the context of decentralization in Indonesia [16]; an assessment of the effect of health system reforms between 2001 and 2006 in Mexico, using a report card approach [17]; an evaluation of the performance of the healthcare delivery system in 16 states of India, using an econometric approach [18]; and monitoring of the rapid expansion of health services in Afghanistan, using a balanced scorecard approach [19]. In Africa, few countries have institutionalized HSPA in their health systems. One of these is the Health Systems Trust of South Africa’s district health barometer, which monitors about 20 set of indicators. The Ugandan Ministry of Health has also been producing an annual health system performance report since 2011, using league table analysis introduced in 2003 to compare performance among districts and determine ‘good’ and ‘poor’ performers, and the reasons why [13].
Over the last decade, Ghana has continually advanced in using various assessment tools to monitor and evaluate the performance of the health sector. For instance, the Ghana Health Service (GHS) has “The Health Sector in Ghana Facts and Figures” that produces annual reports on the performance of some key health sector indicators. There is also the Maternal Health Survey jointly designed and conducted by Ghana Statistical Service (GSS) and GHS to provide data for monitoring key maternal health indicators such as: fertility levels, maternal mortality, family planning methods, pregnancy and postnatal care, abortion and miscarriage [20]. Similarly the GSS in collaboration with other stakeholders in various sectors of government, researchers, civil society and international organizations, has been implementing the Ghana Demographic and Health Survey (GDHS) program that collects, analyzes and disseminates information on demographic and health indicators such as: housing and household characteristics, education, maternal and child health, nutrition, and knowledge and behavior related to HIV/AIDS and other sexually transmitted infections (STIs) [21]. Moreover, through the National Health Accounts (NHA), the country systematically and comprehensively monitors the flow of financial resources in the health system [22]. Above all, the Ministry of Health (MOH) adopted a monitoring and evaluation framework called “The Holistic Assessment Tool” during its 2007–2011 Program of Work (POW) to monitor and assess progress towards achieving the objectives of the country’s Health Sector Medium Term Development Plans (HSMTDPs). It is also to serve as a feedback mechanism to development partners and other key stakeholders of the health sector. The framework has a set of indicators, milestones and targets clustered under the objectives of the national health strategy as defined in the HSMTDPs [23].
In spite of the existence of the aforementioned assessment programs, Ghana does not have a full-fledged HSPA tool that provides a holistic health sector-wide approach to assessing health system performance. For instance, our recent analysis revealed that the Holistic Assessment Tool, which is considered more comprehensive relative to the other assessment methods, does not measure key health system dimensions such as responsiveness of the health system and information systems for health [15]. Per the literature, a comprehensive HSPA encompasses measuring and analyzing how well a health system is meeting its overall goals (i.e. improved health, responsiveness to people’s expectations, social and financial protection and improved efficiency), and how its performance against intermediate outputs (e.g. access, coverage, quality and safety of health services) contributes to achieving these goals [24]. Developing and implementing a Ghanaian HSPA tool that covers the entire health system will bring the country in line with many developed and some developing nations in creating systems and frameworks that monitor and assess the performance of their health systems.