Reorienting health financing for prevention: Ghana´s free primary healthcare reform as a model for LMICs: a commentary

¹Department of Clinical Care, Regional Health Directorate, Ghana Health Service, Savannah Region, Ghana, ²Africa Centre for Health Policy and Systems Strengthening (ACeHP), Ghana, ³Department of Health Policy, Planning and Management, School of Public Health, University of Ghana, Accra, Ghana

^&Corresponding author
Abubakr Ahmed Farhan, Department of Clinical Care, Regional Health Directorate, Ghana Health Service, Savannah Region, Ghana

Commentary    

For decades, primary healthcare has been recognised as the cornerstone of efficient and equitable health systems [1]. Yet in many LMICs, health financing architecture perpetuates a structural imbalance: insurance schemes, designed to protect against catastrophic expenditure, overwhelmingly fund curative and episodic care, while preventive and promotive services remain dependent on fragmented government budgets and volatile donor funding [2-4].

Ghana's 2003 National Health Insurance Scheme (NHIS) was a landmark achievement, replacing the regressive "cash-and-carry" system and expanding population coverage. However, its predominantly treatment-oriented design, rather than one centred on prevention, reflected the broader curative bias in health financing. Preventive services were not part of the original benefits package; critical maternal care exemptions were introduced only later, and many promotive activities were sustained by external partners whose funding is now in decline. This trajectory is common across LMICs and explains why, despite repeated commitments to PHC-oriented UHC, prevention remains everyone's aspiration but no one's dedicated budget line.

This commentary examines whether Ghana's 2026 Free Primary Healthcare (FPHC) programme can address this structural financing gap by creating an explicit purchasing and financing pathway for preventive and promotive care within the NHIS. Given the recency of the reform, this commentary examines FPHC prospectively as a financing and purchasing design rather than as an evaluated intervention. Implementation and outcome data are not yet available to establish its effects; accordingly, the arguments and transferable lessons presented here should be interpreted as propositions about design logic and implementation requirements rather than validated findings.

The reform architecture: a structural shift in purchasing

Free Primary Healthcare should not be understood as a rebranding of the NHIS, nor as a simple fee removal. It is a rebalancing of what the NHIS pays for and how. Two features are foundational. First, the programme defines a prioritised package of preventive and promotive services rather than financing every service delivered through participating PHC facilities. The package includes health education and community outreach; screening and early detection for hypertension and diabetes; cervical cancer screening using visual inspection with acetic acid (VIA) or Lugol's iodine (VILI), clinical breast examination for breast cancer, and prostate cancer screening; nutrition counselling and health-promotion activities; and other population-level preventive interventions. The package also includes major maternal, newborn, child and adolescent health interventions, including antenatal and postnatal care, childhood immunisation, growth monitoring, nutrition counselling, family planning and adolescent health services [5]. These services therefore form part of the broader FPHC service package rather than a narrowly adult screening-focused model. However, inclusion of these services within the FPHC package should not be interpreted as evidence that existing programme-specific financing streams, including vaccine procurement financing, have been fully consolidated into the FPHC payment mechanism; the available public implementation documentation does not yet establish such a financing transition. The services are delivered through CHPS compounds, health centres and the primary-care components of polyclinics. Curative services delivered through these facilities are not replaced by this preventive financing stream but continue under the existing NHIS benefit and payment arrangements. Financing the FPHC package is underpinned by an explicit government budgetary commitment rather than solely by reorganising existing provider payments. Prior to the programme's launch, the Government estimated that FPHC would require approximately GH¢1.2 billion annually, with implementation beginning in 150 underserved districts. The 2026 health-sector budget subsequently allocated approximately GH¢1.5 billion to the FPHC package [6-8]. Programme financing is channelled through the NHIS/NHIA purchasing architecture, and by August 2026 the Government reported that funds had been released for the July-September implementation period, with approximately GH¢35 million allocated for FPHC payments [5]. Thus, "free" primary healthcare refers to removal of payment at the point of use for the defined package rather than an absence of cost: the reform transfers the financing obligation from individual users to public prepayment. This explicit financing commitment is therefore integral to the purchasing reform described below.

The credibility of this financing commitment, however, depends not only on budgetary allocation but also on revenue mobilisation and timely release. FPHC is being implemented within the broader NHIS financing architecture, whose resource base includes the National Health Insurance Levy (NHIL). The uncapping of the NHIL is therefore particularly relevant: the 2026 Budget programmed GH¢11 billion from the uncapped levy for NHIS claims, essential medicines, vaccines, bridging support and FPHC [6,9]. This potentially expands the fiscal space available to the purchasing system, but allocation does not itself guarantee predictable provider financing. Ghana's NHIS has a documented history of delayed provider reimbursement, with consequences for facility liquidity, medicine availability and service delivery [10]. The promise of prospective PBP therefore rests as much on timely and reliable fund release as on the payment formula itself. If quarterly payments are delayed or unpredictable, providers may be unable to plan outreach and preventive activities, weakening the behavioural incentives the reform is designed to create. Financing predictability should consequently be treated as an implementation condition to be monitored, rather than an assumed feature of the reform.

Second, FPHC introduces PBP, through which the NHIA pays providers prospectively each quarter based principally on their catchment population, rather than individual preventive or promotive service claims, with equity considerations incorporated into allocations [5]. This distinction has important equity implications. Using catchment population rather than NHIS enrolment can reduce the risk of excluding uninsured populations from the resource-allocation denominator; however, its equity effect depends on the accuracy of local population estimates and the extent to which allocations account for differences in need. Where population denominators are inaccurate or adjustments for factors such as remoteness and differential service needs are insufficient, an apparently equitable population-based allocation could reproduce existing geographic inequalities. These allocation parameters therefore warrant close monitoring as implementation progresses.

Payments are channelled through Ghana Health Service and CHAG financial arrangements, reaching CHPS zones directly where appropriate accounts exist or through District Health Directorates where they do not. Performance is monitored through coverage indicators, activity reporting and service verification rather than individual claims. If disbursed fully and on schedule, this prospective arrangement could give frontline providers more predictable resources to plan outreach and preventive activities while aligning financial incentives with population health outcomes [12,13].

PBP complements rather than replaces existing NHIS payment arrangements, creating a hybrid purchasing model. Preventive and promotive services are financed prospectively through PBP, while eligible curative services continue under established NHIS claims-based arrangements, principally G-DRG and medicines reimbursement. Thus, providers can receive PBP funding for population-based preventive care while continuing to claim for eligible curative services.

Redesigning access: the front-door reform

Prior to FPHC, access to NHIS-covered services was generally contingent on valid NHIS membership and verification of eligibility, meaning uninsured persons or those with inactive membership could face administrative and financial barriers before receiving covered care. Under FPHC, existing NHIS membership is no longer a prerequisite for accessing the defined FPHC package at participating primary care facilities. Clients may present with an NHIS card or Ghana Card, while those without active NHIS membership can subsequently be supported to enrol or renew. National Health Insurance Scheme membership remains important for curative, referral and higher-level services outside the FPHC package.

Importantly, 'free' under FPHC refers to the defined package being available without user charges at the point of care; it does not eliminate all costs associated with seeking care. Households may still incur transport costs and may face expenses for medicines, diagnostics or services outside the FPHC package, as well as costs arising from referral to higher levels of care. The reform should therefore be understood as reducing selected financial barriers to primary care rather than eliminating all out-of-pocket expenditure associated with an episode of care.

This "front-door" change is not cosmetic. It directly tackles one of the most persistent drivers of poor outcomes in LMICs: delayed presentation due to financial and administrative barriers, even when services nominally exist. The reform allows the health system to detect disease risk early and channel patients appropriately, while insurance enrolment becomes a downstream event - a consequence of system interaction, not a gatekeeper to care. However, the effect on NHIS enrolment is uncertain. Removing membership as a prerequisite for primary care could reduce the marginal incentive for healthier individuals to enrol, potentially worsening adverse selection. FPHC contact does not automatically confer NHIS membership; rather, clients without active membership can be supported to enrol or renew, while NHIS remains important for referral and higher-level services outside the FPHC package. Whether this interaction ultimately increases or weakens enrolment therefore remains an empirical question. Evidence from Ghana [14] shows that reducing financial barriers to NHIS enrolment can increase coverage, although this does not establish that free access to care itself will increase insurance enrolment.

Strategic provider payment

The shift to prospective Population-Based Payment for preventive and promotive primary care is critical. Evidence suggests that population-based payment, coupled with accountability for defined service outputs, can improve both equity and efficiency in PHC delivery [12,13]. In Ghana, if implemented as designed and disbursed predictably, the mechanism could provide participating providers with a more predictable financing envelope, enabling them to invest in community-based preventive work such as home visits, health talks, and screening drives that fee-for-service models ignore. It also discourages unnecessary referrals and over-treatment, as payments are determined prospectively in relation to the defined population served.

Prospective PBP also creates a counter-incentive: because payment is decoupled from the volume of services delivered, providers may have an incentive to under-provide care. Under FPHC, preventive and promotive services therefore do not generate individual claims for reimbursement; rather, service delivery is monitored through coverage indicators, activity reporting and service verification. These mechanisms are intended to verify that funded activities are delivered without converting the payment system back into claims-based reimbursement. The effectiveness of PBP will consequently depend on the strength of these monitoring and accountability arrangements in safeguarding against under-provision. Ghana's use of population-based payment is not without precedent. The NHIS piloted capitation in the Ashanti Region from 2012, but sustained provider and stakeholder resistance contributed to its suspension in 2017 [11,15]. The FPHC arrangement differs in an important respect: Population-Based Payment is primarily attached to a defined preventive and promotive service package rather than serving as the principal payment mechanism for the broader curative primary-care package. Whether these design differences are sufficient to avoid the problems encountered under the earlier capitation pilot remains an important implementation question.

Ambition with discipline: phased implementation

FPHC's policy ambition (free primary healthcare for all) is broad by design, signalling a national reorientation toward PHC. However, the rollout is intentionally sequenced. Phase I focuses on high-impact, cost-effective preventive services delivered through existing CHPS compounds, health centres, and polyclinic public health units. Curative care continues under current NHIS rules [5,8]. This pragmatic phasing mirrors the incremental expansion strategy seen in successful UHC reforms globally, where direction was set ambitiously but expansion was tied to fiscal capacity [16]. This sequencing is particularly important because fiscal discipline requires not only matching programme scope to budgetary commitments, but also ensuring that those commitments translate into predictable releases to providers. Other LMICs frequently face the dilemma of whether to narrow ambition to match immediate capacity or to set an expansive vision and phase carefully. Ghana's phased design illustrates a policy approach in which the scope of entitlement is intended to expand progressively alongside fiscal and delivery capacity; whether this sequencing proves feasible and sustainable will require empirical assessment as implementation matures.

System alignment as the test of sustainability

The risk that financing promises outpace delivery capacity is real. Dedicated financing for prevention cannot by itself generate screening, outreach or home visits where CHPS zones lack sufficient community health officers, essential commodities, basic diagnostics or functional service capacity [17]. These supply-side constraints are particularly important for Phase I because its preventive and promotive package depends heavily on frontline personnel and reliable availability of screening and outreach inputs. The effectiveness of FPHC will therefore depend not only on aligning the service package, purchasing and accountability arrangements, but also on ensuring that participating PHC facilities have the workforce, commodities and operational capacity required to deliver the funded services.

Ghana's design should also be interpreted against wider African experience. Evaluations of user-fee removal and free-care policies in Francophone West Africa, including Burkina Faso and Niger, show that removing charges can increase utilisation, particularly for maternal and child health services, but that effects depend on adequate financing, timely reimbursement, provider capacity and implementation fidelity [18-20]. African experience with strategic purchasing, including capitation and performance-based financing, similarly demonstrates that changing payment mechanisms can alter provider incentives, but outcomes depend on payment adequacy, accountability arrangements and health-system capacity. These experiences caution against treating FPHC's design features as universally transferable solutions; rather, they provide propositions whose effectiveness will depend on the institutional, fiscal and delivery context in which they are implemented.

Transferable design lessons and caveats for LMICs

These design features offer potentially transferable lessons for LMICs, but their relevance is conditional on fiscal capacity, provider incentives, population-allocation mechanisms and delivery-system readiness. They should therefore be interpreted as design propositions rather than evidence of demonstrated effectiveness. Ghana's FPHC reform illustrates a set of design principles that may be relevant beyond its borders: i) Finance prevention explicitly: do not assume that expanding insurance coverage automatically funds preventive care. Prevention must have a defined package and a dedicated budget line inside or alongside the national purchasing system. ii) Use population-based payment to drive population health: Prospective, capitated or global budgets for primary care providers shift the incentive from treating the sick to keeping populations healthy. iii) Flip the access sequence: allow entry into the system before enforcing enrolment. This decouples care-seeking from administrative hurdles, enables earlier risk detection, and uses service interaction as a pathway to expand coverage. iv) Phase boldly but fiscally: Set an ambitious policy direction for UHC centred on PHC, but sequence implementation based on fiscal space, starting with high-impact, low-cost preventive services. v) Align purchasing, delivery, and accountability: sustainable system change requires that the service package, provider payment, service verification, and performance monitoring are designed as one integrated architecture. These principles reinforce that UHC is not only about expanding the proportion of the population covered, but about restructuring how health financing functions to produce health.

Conclusion     

Ghana's FPHC reform represents an important attempt to reorient health financing toward prevention and population health by defining a preventive and promotive package, introducing population-based provider payment, reducing barriers at first contact, and sequencing implementation alongside fiscal and delivery considerations. These design features offer potentially useful propositions for LMICs confronting similar curative biases in health financing, but they should not yet be interpreted as evidence of effectiveness. Whether the reform ultimately improves preventive service coverage, equity, financial protection and population health outcomes will depend on implementation fidelity, adequate and predictable financing, provider and system capacity, and sustained monitoring. Ghana's experience should therefore be followed as an evolving policy experiment from which stronger transferable lessons can be drawn as implementation evidence accumulates.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Abubakr Ahmed Farhan: conceptualization, writing - original draft, writing - review and editing. Issahaku Yussif: Writing - review and editing. All authors have read and approved the final version of this manuscript.

References