Hospital-level patterns of COVID-19 mortality in Ghana: a retrospective analysis of 2020-2022 routine surveillance data

Abstract

Introduction: COVID-19 exposed vulnerabilities in health systems, particularly in low- and middle-income countries. Ghana was amongst the hardest hit in West Africa, yet little is known about how outcomes varied across its tiered hospital system. This study aimed to assess the distribution of COVID-19 cases, deaths and Case Fatality Rates (CFR) across hospital levels in Ghana, and to examine patient characteristics associated with mortality. Methods: we conducted a retrospective cross-sectional study using secondary data from COVID-19 surveillance records of the Ghana Health Service between March 2020 and February 2022. Variables included patient age, sex, comorbidities, outcomes and reporting facility. Facilities were categorized as primary, secondary, or tertiary. Descriptive statistics and CFR were computed by hospital level. Results: overall, 152,896 confirmed COVID-19 cases and 1,442 deaths were recorded, with healthcare facilities accounting for 71,404 cases and 1,210 deaths. Primary facilities reported most cases (59.3%), while tertiary facilities recorded the highest proportion of deaths (39.5%). In-hospital CFR was 13.11% [95% CI: 12.37-13.87], increasing with care level: 10.08% in primary, 14.16% in secondary, and 16.78% in tertiary facilities. Mortality was higher among older adults (62 years (IQR 49-75), p < 0.001), males (56.9%, p = 0.021) and comorbid patients (52.7%, p < 0.001). Secondary and tertiary facilities managed disproportionately older and comorbid patients compared to primary facilities, with cases concentrated in urban areas of southern Ghana. Conclusion: mortality increased across hospital levels, reflecting referral of more severe cases to higher-level facilities. Strengthening primary care, hospital preparedness, and referral systems is critical for future pandemic readiness.