Free Primary Health Care Must Help Ghana Breathe

Ghana’s Free Primary Health Care (FPHC) Programme, launched in April 2026, represents an important step towards universal health coverage. Its initial rollout across underserved districts places prevention, early detection and referral at the centre of primary care, including community-based screening for hypertension and diabetes.

By deploying community health workers to screen people for these conditions, the Ministry of Health is taking the fight to some of the nation’s most dangerous silent killers. Yet, as this ambitious programme reaches communities across Ghana, a serious and potentially life-threatening gap remains: many Ghanaians continue to struggle in silence with chronic respiratory illness.

To address this omission, Ghana should incorporate a practical respiratory-health pathway into the FPHC programme. This should not involve attempting to diagnose asthma using a single device or test. Instead, the pathway should combine symptom and risk assessment, appropriately supervised peak-flow monitoring, the selective use of fractional exhaled nitric oxide (FeNO) testing, and clear referral protocols for spirometry and clinical evaluation.

Properly designed, such a pathway could identify high-risk patients earlier, reduce avoidable emergencies and bring respiratory care closer to underserved communities.

The Hidden Burden of Asthma
In many Ghanaian households, asthma remains poorly understood, under-recognized and surrounded by misconceptions. Recurrent cough, wheezing, chest tightness and breathlessness may be dismissed as a passing infection, attributed to environmental conditions or interpreted through spiritual beliefs.

Consequently, some children and adults enter the health system only when an acute attack forces them to seek emergency care. By then, a manageable chronic condition has become a frightening and potentially fatal crisis.

Access to objective respiratory testing is also uneven. Spirometry, particularly testing before and after bronchodilator administration, remains the preferred method for confirming variable airflow limitation in many patients old enough to perform the procedure reliably.

However, equipment, trained personnel, maintenance and quality-assurance systems remain limited or unavailable in many low-resource settings. Evidence from Ghanaian health facilities and experts has similarly identified gaps in basic respiratory diagnostic resources, particularly outside major urban centres. For patients in rural and underserved communities, distance, transportation expenses and referral costs may delay or prevent confirmation of suspected asthma.

Delayed recognition carries a heavy human and financial cost. A University of Ghana study involving 90 caregivers at the Princess Marie Louise Children’s Hospital estimated average household caregiving costs at approximately GH¢5,890 over the study’s recall period, with direct expenses accounting for about 93 percent of the total. This study illustrates how medicines, treatment, transportation and lost working time can place considerable strain on families when asthma is poorly controlled. Repeated emergency care also places avoidable pressure on hospitals and the National Health Insurance Scheme.

We are spending a fortune managing emergency failures when we could spend far less on early identification and intervention.

A Practical Pathway: Symptoms, Airflow and Inflammation

The solution is not to place sophisticated diagnostic responsibilities on every community volunteer. Ghana needs a tiered pathway that matches each tool and responsibility to the appropriate level of care.

Frontline workers can identify symptoms, risk factors and danger signs. Trained primary-care professionals can assess airflow. Selected diagnostic hubs can use FeNO testing where appropriate, while district facilities can provide spirometry, clinical evaluation or specialist referral when the diagnosis remains uncertain.

Step 1: Symptom Assessment and Peak-Flow Monitoring

Mechanical peak-flow meters are relatively affordable, portable and independent of electricity. They measure peak expiratory flow, which can help demonstrate variable airflow limitation when readings are taken correctly and monitored over time.

However, a single peak-flow reading cannot diagnose asthma, and a normal result does not exclude the condition. Under the FPHC programme, trained personnel could use standardized symptom questions and supervised peak-flow monitoring to identify patients who require further assessment.

Anyone presenting with severe breathlessness, low oxygen saturation or other danger signs should be referred immediately for urgent medical care.

Step 2: Selective FeNO Testing
FeNO testing measures the concentration of nitric oxide in exhaled breath and can provide evidence of type 2, or eosinophilic, airway inflammation. A high result can strengthen a suspected asthma diagnosis and may help identify patients who are likely to respond to inhaled corticosteroids.

FeNO is not, however, an absolute marker of asthma. Allergic rhinitis, smoking, medication use and other factors can influence the result, while a low reading does not rule out the condition. FeNO testing should therefore support, rather than replace, clinical assessment and lung-function testing.

Age and technique also matter. Standard peak-flow, spirometry and single-breath FeNO manoeuvres can be difficult for preschool children. Current international guidance generally recommends relying primarily on clinical assessment and careful follow-up in children under five until reliable objective testing becomes possible.

For older children and adults, FeNO testing may provide valuable additional information when conducted by trained personnel according to clear quality standards and referral protocols. Used selectively rather than indiscriminately, it could improve diagnostic confidence and support more appropriate treatment decisions.

Make Community Pharmacists Part of the Referral Network

The respiratory-health pathway should extend beyond public clinics. Community pharmacies are often among the most accessible points of care for people seeking help for coughing, wheezing, chest tightness or frequent reliever-inhaler use.

This accessibility gives pharmacists an important opportunity to identify poor asthma control, correct inhaler technique, detect potentially unsafe patterns of self-medication and refer high-risk patients for appropriate assessment and care.

The strongest evidence supports pharmacy-based symptom and asthma-control screening, medication review, inhaler education and structured referral. Peak-flow monitoring may be used as an additional assessment tool where pharmacists and other staff have received appropriate training.

FeNO testing should initially be limited to carefully evaluated pilot sites linked to qualified clinicians and confirmatory testing. This staged approach would make effective use of pharmacists’ accessibility without requiring them to make definitive diagnoses based on a single measurement.

Build on the Network Already in Place
Ghana does not need to create an entirely new delivery system. The FPHC programme already works through Community-based Health Planning and Services compounds, health centres, community outreach points, frontline health professionals and trained volunteers.

Respiratory screening and referral can be incorporated into this network through a standardized algorithm, clearly defined scopes of practice, practical training and reliable referral pathways.

Implementation should begin with feasible essentials: brief symptom screening, recognition of emergency warning signs, access to pulse oximetry where possible, inhaler-technique support and supervised peak-flow monitoring for suitable patients.

Portable FeNO devices could subsequently be introduced at selected primary-care and pharmacy hubs, with results interpreted alongside symptoms, medical history and other objective tests.

District hospitals should remain responsible for diagnostic confirmation, complex cases and severe respiratory disease. Data from the first implementation sites should be used to evaluate costs, diagnostic yield, referral completion, patient outcomes and operational feasibility before any nationwide expansion.

A Call to Act Before the Next Attack
From seasonal harmattan dust and household air pollution to traffic emissions and occupational exposures, many Ghanaians encounter conditions that can trigger or aggravate respiratory symptoms.

Universal health coverage cannot be achieved if chronic respiratory disease becomes visible to the health system only when a patient arrives at an emergency department struggling to breathe.

The Ministry of Health should add a phased asthma-identification and referral pathway to the FPHC programme, beginning in high-burden and underserved districts. The model should combine community-based symptom assessment, appropriately supervised peak-flow monitoring, selective FeNO testing, pharmacy engagement and access to confirmatory spirometry and clinical evaluation.

It must also connect diagnosed patients to affordable inhaled medicines, inhaler education, written asthma action plans and continuing care.

Ghana has built a platform for prevention. It should now use that platform to ensure that every citizen has a fair chance to breathe.

Prof. Victor Wutor
Asthma Ghana