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Learn more: PMC Disclaimer | PMC Copyright Notice BMC Health Serv Res . 2026 Mar 9;26:529. doi: 10.1186/s12913-026-14324-5 Search in PMC Search in PubMed View in NLM Catalog Add to search Digital health system integration in Ghana: a scoping review of governance arrangements, interoperability aspirations, and regulatory gaps Simon Nyarko Simon Nyarko 1 Department of Health Policy, Planning and Management, School of Public Health, University of Ghana, Accra, Ghana Find articles by Simon Nyarko 1, ✉ , Roger A Atinga Roger A Atinga 2 Department of Health Services Management, University of Ghana School of Business, Accra, Ghana Find articles by Roger A Atinga 2 , Dennis Bardoe Dennis Bardoe 3 Department of Public Health Education, Akenten Appiah-Menka University of Skills Training and Entrepreneurial Development, Mampong, Ghana Find articles by Dennis Bardoe 3 , Abigail N Owusu Abigail N Owusu 4 Nursing and Midwifery Council (NMC), P.O. Box MB 44, Ministries, Accra Ghana Find articles by Abigail N Owusu 4 Author information Article notes Copyright and License information 1 Department of Health Policy, Planning and Management, School of Public Health, University of Ghana, Accra, Ghana 2 Department of Health Services Management, University of Ghana School of Business, Accra, Ghana 3 Department of Public Health Education, Akenten Appiah-Menka University of Skills Training and Entrepreneurial Development, Mampong, Ghana 4 Nursing and Midwifery Council (NMC), P.O. Box MB 44, Ministries, Accra Ghana ✉ Corresponding author. Received 2025 Dec 30; Accepted 2026 Mar 4; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13085690 PMID: 41803867 Abstract Background Digital health systems are increasingly central to health system performance, yet many low- and middle-income countries continue to struggle with integrating proliferating platforms into coherent national infrastructures. These challenges are often attributed to technical or capacity constraints, but less attention has been paid to how digital health integration is governed in practice. Ghana is frequently cited as an early adopter of digital health in sub-Saharan Africa, but persistent fragmentation raises questions about how national digital health integration is executed. Methods We conducted a scoping review in accordance with PRISMA-ScR guidelines to examine governance arrangements, regulatory frameworks, and interoperability provisions that shape the integration of Ghana’s national digital health systems. Four bibliographic databases and two search engines were searched for peer-reviewed and grey literature, with no restriction on publication date. Eligible sources included empirical studies, policy documents, strategies, technical reports, and programme evaluations addressing digital health governance, regulation, data governance, or interoperability in Ghana. Results Twenty-two sources met the inclusion criteria. Authority for digital health governance is distributed across multiple health and non-health institutions, with no single body exercising comprehensive stewardship or enforcement. Legal and policy instruments articulate principles for coordination, interoperability, data protection, and cybersecurity, but interoperability is consistently framed as a strategic objective rather than a mandatory condition for system deployment or continuation. In practice, governance and interoperability arrangements operate unevenly, characterized by parallel platforms, partial data flows, manual workarounds, and variable compliance with security safeguards. Persistent gaps are associated with fragmented mandates, weak enforcement mechanisms, donor-driven implementations, and constrained subnational capacity. Conclusion Ghana’s digital health integration challenges reflect a governance execution gap rather than an absence of strategies or technologies. The findings highlight the need to shift from strategy-led coordination toward enforceable, rule-based governance, with broader relevance for countries seeking sustainable digital health integration. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-026-14324-5. Keywords: Digital health governance, Interoperability, Health information systems, Data governance, Ghana Background Digital health systems are no longer peripheral to health system functioning. Across many countries, digital platforms now underpin routine service delivery, surveillance, financing, logistics, and clinical care [ 1 , 26 ]. However, the rapid proliferation of digital health tools has not consistently translated into integrated, interoperable health information infrastructures, particularly in low- and middle-income countries (LMICs). Instead, multiple reviews report a familiar pattern: expansion of digital health initiatives alongside persistent fragmentation, parallel systems, and limited data sharing across platforms and institutions [ 14 , 16 , 54 ]. Much of the existing literature attributes these challenges to technical constraints, infrastructure gaps, or insufficient policy frameworks [ 25 , 32 , 55 ]. While these factors are important, they offer only a partial explanation. Interoperability and system integration are not purely technical outcomes but governance outcomes, shaped by how authority, accountability, incentives, and enforcement are structured [ 11 , 22 ]. Robust integration requires not only standards and architectures but also institutions with the mandate and capacity to enforce compliance, align investments, and coordinate actors across sectors and system levels. Where governance arrangements rely primarily on guidance rather than enforceable rules, fragmentation is a predictable outcome [ 16 , 42 , 43 ]. In this review, digital health systems integration is treated as an operational, system-level concept rather than a technology- or workflow-specific one. We define integration as the extent to which multiple digital health platforms are institutionally coordinated, technically interoperable, and governed through shared rules, standards, and oversight mechanisms across the health system. This definition reflects the review’s focus on ecosystem-wide coherence rather than on the adoption of individual digital tools within specific service-delivery functions. Governance is similarly defined as a practical construct, referring to the formal allocation and exercise of authority through institutional mandates, legal and policy instruments, coordination mechanisms, interoperability requirements, and enforcement processes. In this paper, governance is examined in terms of how these arrangements operate in practice to shape system integration, rather than solely by their intended outcomes. Ghana provides a revealing case for examining these dynamics. The country is often recognized as an early adopter of digital health in sub-Saharan Africa, having articulated national eHealth and health information strategies more than a decade ago and implemented several national-scale digital platforms (Ministry of Health, [ 35 , 46 ]). Routine health data reporting is anchored in a nationwide health information system, while additional digital tools support logistics management, disease surveillance, insurance claims processing, and facility-level clinical care (Ghana Health Service, [ 18 ]; Ministry of Health Ghana, [ 36 ]). On paper, this landscape reflects substantial progress and policy commitment. In practice, however, evidence suggests that Ghana’s digital health ecosystem remains fragmented. Empirical studies and institutional assessments document parallel platforms, duplicated data entry, incomplete system linkages, and reliance on manual workarounds across national, subnational, and facility levels [ 2 , 40 , 41 ]. Hospital information systems often operate independently of national reporting platforms, donor-supported systems frequently bypass shared standards, and interoperability remains limited to partial or one-directional data exchange [ 3 , 49 ]. These challenges persist despite the existence of multiple policies, strategies, and technical frameworks that explicitly promote coordination and interoperability. Ghana has also established cross-sectoral legal and regulatory frameworks relevant to digital health governance, including statutory provisions for data protection and cybersecurity (Cyber Security Authority, [ 15 ]). While these instruments articulate important principles and obligations, recent assessments indicate uneven implementation within the health sector, with variable compliance and limited routine enforcement (IIPGH, [ 24 ]). These developments underscore that digital health has become integral to Ghana’s health system, while also exposing weaknesses in the operationalization of governance arrangements. Despite the growing body of work on digital health in Ghana, existing studies tend to focus on individual systems, technical performance, or user experiences, rather than on how integration is governed across the ecosystem [ 30 , 33 ]. Global guidance on digital health governance provides high-level recommendations but offers limited insight into how institutional authority, enforcement mechanisms, and interoperability requirements function in specific country contexts (World Bank, [ 56 ]). As a result, policymakers and partners lack a consolidated, system-level understanding of how digital health integration is governed in practice and why fragmentation persists despite dense policy frameworks. This scoping review addresses this gap by examining how the integration of Ghana’s national digital health systems is governed. It synthesizes heterogeneous peer-reviewed and grey literature to examine governance arrangements, regulatory frameworks, and interoperability provisions operating across institutions and system levels. By consolidating dispersed evidence, the review aims to clarify where governance execution breaks down and to draw lessons relevant to other LMICs seeking to move from strategy-led digital health expansion toward enforceable and sustainable integration. Research questions The research questions guiding this review are designed to examine how digital health integration is governed in practice, with particular attention to the alignment of institutional authority, interoperability requirements, and enforcement mechanisms across Ghana’s health system. The overarching question in this study is: How is the integration of Ghana’s national digital health systems governed, and how do existing governance, regulatory, and interoperability arrangements operate in practice to shape system integration, data sharing, trust, and sustainability? To address this overarching question, four specific questions were examined: Which institutions and actors hold formal authority for governing, regulating, and coordinating national digital health systems in Ghana, and how are their mandates defined and exercised in practice? What governance structures, legal instruments, regulatory frameworks, and interoperability standards currently guide the integration and use of national digital health systems in Ghana? How do existing governance and interoperability arrangements operate across national, subnational, and facility levels, particularly with respect to coordination, enforcement, and system integration? Why do regulatory, governance, and interoperability gaps persist, and what system-level consequences do these gaps create for data sharing, integration, trust, and sustainability within Ghana’s digital health ecosystem? Method Study design A scoping review was selected to systematically map and synthesize a heterogeneous body of evidence on digital health governance, regulation, and interoperability in Ghana. The available evidence spans peer-reviewed studies, government policies, legal instruments, technical reports, and other grey literature, which are not amenable to effectiveness-focused systematic review approaches. A scoping review is therefore appropriate for examining how governance arrangements are specified and operate in practice, identifying gaps, and clarifying concepts within a fragmented, multidisciplinary evidence base [ 48 ]. The conduct and reporting of this scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [ 53 ]. Eligibility criteria Eligibility criteria were defined a priori and structured by study characteristics, scope, and accessibility to ensure consistent and transparent study selection. Table 1 presents the inclusion and exclusion criteria used to select peer-reviewed and grey literature sources for the scoping review, organized by study characteristics, scope, publication source, accessibility, and language. Table 1. Eligibility criteria for inclusion in the scoping review Criteria Category Inclusion Criteria Exclusion Criteria Rationale Study type Empirical studies, policy analyses, reviews, technical reports, evaluations, and conceptual papers related to digital health governance, regulation, interoperability, or data governance. Editorials, protocols, and opinion pieces lacking substantial evidence, and conference abstracts without full text Scoping reviews aim to map the scope and characteristics of evidence, rather than evaluate effectiveness. Broad inclusion captures diverse evidence types relevant to governance and policy questions. Population / Focus Digital health systems, health information systems, or governance arrangements involving health sector institutions, regulators, or implementers. Studies that focus solely on individual patient outcomes or clinical effectiveness without addressing governance or system-wide relevance. The review emphasizes system-level governance and policy, not individual clinical effects. Geographical scope Studies, reports, or documents focused on Ghana Studies with no substantive relevance to Ghana Scoping reviews require clearly defined boundaries. Focusing on a specific country ensures contextual relevance and policy usefulness. Publication source Peer-reviewed journals, government documents, policy briefs, institutional reports, donor and partner reports, and other grey literature. Blog posts, media articles, or informal commentaries without institutional authorship or documentation Evidence of governance is often found outside academic journals. Including grey literature is essential for a complete understanding of the ecosystem. Duplication Most complete and recent version of a study or document Duplicate publications or earlier versions of the same document Prevents double-counting evidence while keeping the most authoritative and current source. Accessibility Full-text documents available online or through institutional access Records with no accessible full text Transparent data charting and synthesis require full access to source materials, as recommended by PRISMA-ScR. Language Publications in English Publications in languages other than English English is the official language of governance and policy documentation in Ghana. Resource constraints preclude reliable translation. Open in a new tab Information source and search strategy Searches in 4 databases and 2 search engines covered peer-reviewed and grey literature sources to capture evidence on digital health governance, regulation, and interoperability in Ghana. Electronic databases searched included PubMed, IEEE Xplore digital library, Ovid via MEDLINE, and the Association of Computing Machinery (ACM) digital library. The search engines used were Google and Google Scholar. Searches were conducted from November 10, 2025, to December 21, 2026. These were chosen to cover health systems research, policy analysis, and interdisciplinary digital health literature. The search was strategized to identify literature on digital health governance, regulation, data governance, and interoperability in Ghana. Search terms included but not limited to “digital health,” “eHealth,” “health information systems,” “electronic health records,” “electronic medical records,” “mHealth,” and “telemedicine,” combined with “governance,” “policy,” “regulation,” “data governance,” and “interoperability,” and the geographic term “Ghana.” Search strings were developed by connecting the search terms with the Boolean operators ‘AND’ & ‘OR’. In addition to peer-reviewed literature, the review included evidence from grey sources such as government documents, policy reports, technical reports, and partner publications identified through Google and Google Scholar. Reference lists of included sources were also screened to identify additional relevant documents. When necessary, institutional reports were updated to their most recent versions to prevent duplication. Supplementary Table S1 details the search terms, Boolean operators, and database-specific search strings used across bibliographic databases and search engines. Selection of sources of evidence All records identified through database and grey literature searches were imported into a reference management system, and duplicates were removed. Screening was conducted in two stages. Titles and abstracts were first screened independently by two reviewers (SN and ANO) against the predefined eligibility criteria. Full texts of potentially relevant sources were then retrieved and assessed separately by the same two reviewers. Disagreements at either screening stage were resolved through discussion, and where consensus could not be reached, a third reviewer (DB) adjudicated. Supplementary Table S2 presents the data extraction matrix for all included sources, providing an overview of document focus and summarized findings, with specific attention to governance and institutional authority, interoperability arrangements and system integration, and identified regulatory gaps and enforcement constraints. Data charting process and data items Data were extracted using a standardized charting form developed by the review team, aligned with the review objectives and key concepts in the digital health governance and interoperability literature. The initial charting template was piloted independently by the reviewers on a subset of included sources and refined through team discussion to ensure consistent interpretation of data items and uniform application across sources. The finalized charting form captured publication characteristics (author, year, document type, and source), the substantive focus of each study or document, the digital health system or domain addressed, and the health system level (national or subnational). Governance-related data items included responsible institutions and actors, formal roles and mandates, coordination and oversight mechanisms, and institutional relationships. Regulatory and policy variables captured relevant laws, strategies, guidelines, and standards, as well as data governance provisions related to privacy, security, access, and data reuse. Interoperability-related items included reported standards, platforms, integration mechanisms, and system linkages. Data were also charted on reported challenges, gaps, and forms of fragmentation affecting system integration, trust, and sustainability, as well as any proposed solutions or recommendations. Data charting was conducted independently by three reviewers (SN, ANO, and DB), with discrepancies resolved through discussion or adjudication by a fourth reviewer (RAA). No direct contact with authors or institutions was undertaken, as extraction was limited to publicly available information. Where documents addressed multiple systems or policies, data were charted at the level most relevant to governance and interoperability, and conceptually similar items were grouped during synthesis to enable comparison across sources. Critical appraisal of individual sources of evidence No formal critical appraisal of individual sources was performed. This choice was intentional and aligned with the goals of the scoping review, which aimed to explore the scope and features of evidence on digital health governance, regulation, and interoperability in Ghana rather than evaluate methodological quality or risk of bias. Because the review included various types of evidence, such as policy documents, technical reports, and other grey literature, applying a single quality appraisal tool was not suitable. Instead, all sources were regarded as descriptive data to identify governance structures, policy frameworks, and systemic gaps. Synthesis of results The synthesis followed a descriptive and analytical approach consistent with scoping review methodology. Charted data were first summarized descriptively by source type, digital health domain, and health system level. An iterative analytical process was then used to group findings across sources into thematic categories reflecting governance arrangements, regulatory instruments, interoperability provisions, and enforcement mechanisms. Patterns of convergence, divergence, and fragmentation were identified across institutions and system levels, and synthesized narratively to highlight recurring governance gaps and their system-level implications. Results Characteristics of included sources Twenty-two sources met the inclusion criteria. Figure 1 illustrates the identification, screening, eligibility assessment, and inclusion of sources in the scoping review. As summarized in Fig. 2 , the included studies comprised 10 peer-reviewed journal articles (45.45%), 8 government policies, strategies, plans, and statutory or administrative regulatory instruments (36.36%), 2 technical reports or programme evaluations (9.09%), and 2 other grey literature sources (9.09%). Included sources were published between 2005 and 2025, with most (14; 63.63%) published from 2020 to 2025, 6 (27.27%) from 2011 to 2019, and 2 (9.09%) in 2010 or earlier. Governance and institutional authority were the most frequently addressed analytical focus (15 sources), followed by interoperability or system integration (12 sources) and implementation or operational challenges (11 sources). Fewer sources examined legal and regulatory frameworks (10 sources) or data protection and cybersecurity (8 sources). Most sources focused on national-level systems or policies (17 sources), with fewer addressing subnational (7 sources) or facility-level contexts (6 sources). Fig. 1. Open in a new tab PRISMA-ScR flow diagram illustrating the study identification, screening, eligibility assessment, and inclusion process for the scoping review Fig. 2. Open in a new tab Characteristics of included sources ( n = 22). Summarizes the characteristics of included sources by publication type, year of publication, analytical focus, and health system level addressed Distribution of institutional authority for digital health governance in Ghana Authority over digital health integration in Ghana is not absent but fragmented and functionally segmented, limiting enforceable coordination. The reviewed evidence indicates that formal authority for governing Ghana’s national digital health systems is distributed across multiple institutions, with no single body exercising comprehensive stewardship over policy direction, system integration, interoperability enforcement, and regulatory oversight (Government of Ghana, [ 20 ]; Ministry of Health, [ 35 ]; Ministry of Health Ghana, [ 36 ]). Mandates are defined through a combination of health-sector policies, cross-sectoral legislation, and operational guidelines, resulting in overlapping responsibilities without binding coordination mechanisms. At the sector level, the Ministry of Health retains formal responsibility for digital health policy direction through national eHealth, ICT, and health information strategies (Ministry of Health, [ 34 ]). These instruments articulate coordination and stewardship roles but do not confer enforcement authority to compel compliance across implementing agencies, autonomous institutions, or partner-supported systems. None of the reviewed policy documents specifies sanctions, certification requirements, or binding compliance thresholds related to digital health integration or interoperability. Operational authority over routine public-sector digital health systems is exercised primarily by the Ghana Health Service, particularly through management of the national health information system and the issuance of standard operating procedures governing reporting and supervision ([ 2 , 8 ]; Ghana Health Service, [ 17 ]). However, this authority is largely confined to service delivery systems under the Ghana Health Service’s control and does not extend to autonomous agencies, teaching hospitals, or externally governed platforms [ 9 ]. Regulatory authority relevant to digital health resides largely outside the health sector. Cross-sectoral bodies such as the Data Protection Commission and the Cyber Security Authority are mandated to regulate the processing of personal data and critical information infrastructure, respectively (Cyber Security Authority, [ 15 ]; Parliament of Ghana, [ 47 ]). While these institutions set standards and conduct assessments, the reviewed sources provide limited evidence of routine, sector-wide enforcement actions within the health system. Additional actors, including the National Health Insurance Authority and teaching hospitals, retain independent authority over their information systems, with no binding requirements to align with national health platforms or interoperability standards [ 4 , 9 ]. Overall, institutional authority over digital health governance in Ghana is dispersed across policy stewardship, system operations, regulation, and standard-setting functions, with limited mechanisms to align mandates or resolve conflicts. The distribution of authority and its implications for coordination are summarized in Table 2 . Table 2. Governance structures, legal instruments, and interoperability frameworks shaping national digital health integration in Ghana Instrument / Framework Instrument type Governing body System level What it formally governs Interoperability or data-sharing provisions What is not specified Data Protection Act, 2012 (Act 843) Law Data Protection Commission Cross-sectoral Personal data processing, consent, security, lawful disclosure Permits data exchange subject to compliance with statutory principles No health-specific standards or technical guidance Cybersecurity Act, 2020 Law Cyber Security Authority Cross-sectoral Protection of critical information infrastructure Security obligations relevant to interoperable systems No digital health-specific interoperability standards Ghana eHealth Strategy (2010) Strategy Ministry of Health Health sector Vision, principles, and proposed governance structures Alignment with e-GIF; proposed use of international standards No binding enforcement mechanisms Health Information Systems Strategic Plan (2022) Strategic plan MoH / GHS Health sector Coordination of health information systems Proposes sector-wide interoperability standards Standards not operationalized GHS Digital Health Policy (2023–2027) Policy Ghana Health Service GHS service delivery Governance structures for digital health Commits to interoperable systems and open standards No cross-agency enforcement authority e-Government Interoperability Framework (e-GIF) Technical framework NITA Whole-of-government Organizational, semantic, and technical interoperability Defines APIs, ESB, standards, compliance reviews Health sector adoption not mandated HIS Standard Operating Procedures (2020) Operational guideline GHS Service delivery Data collection, validation, reporting Allows controlled automation into DHIMS2 No national interoperability architecture NHIS e-claims rules Administrative rules NHIA Insurance systems Claims submission and reimbursement Uses standard codes (ICD, DRG, ATC) No routine linkage to other health systems Open in a new tab Governance instruments and interoperability frameworks shaping digital health integration Ghana’s governance instruments articulate strong principles but function primarily as guidance rather than enforceable controls. Table 2 summarizes the formal governance instruments shaping Ghana’s national digital health systems, highlighting their legal status, institutional custodians, scope of application, and interoperability provisions. The review identifies a layered set of governance instruments shaping digital health integration in Ghana, spanning cross-sectoral legislation, health-sector strategies and policies, government-wide technical frameworks, and operational guidelines. While these instruments collectively articulate expectations for coordination, interoperability, data protection, and cybersecurity, they vary substantially in legal force, specificity, and enforceability. At the statutory level, cross-sectoral laws provide the most legally binding instruments relevant to digital health. The Data Protection Act, 2012 (Act 843) and the Cybersecurity Act, 2020 establish obligations regarding lawful data processing, security safeguards, and the protection of critical information infrastructure. However, these statutes apply to the health sector in scope rather than by design and do not specify health-sector interoperability standards, technical architectures, or mandatory system-integration requirements. Health-sector strategies and policies, including the national eHealth Strategy and the Health Information Systems Strategic Plan, define objectives for digital health coordination and integration and consistently reference interoperability as a guiding principle (Ghana Health Service, [ 18 ]). Across these documents, interoperability is framed as a strategic objective rather than as a prerequisite for system procurement, deployment, or continued operation. The reviewed sources do not identify provisions specifying timelines, certification processes, or sanctions for non-compliance. Technical guidance on interoperability is provided primarily through the government-wide e-Government Interoperability Framework, which defines organizational, semantic, technical, and security layers for data exchange (Government of Ghana, [ 20 ]). Although this framework specifies standards and interface principles, the evidence does not document systematic operationalization within the health sector or mandatory adoption tied to health system deployment. Operational instruments, including health information management standard operating procedures, shape integration through reporting workflows and limited automation into the national health information system. These arrangements enable partial, often one-directional data exchange but do not constitute a comprehensive interoperability framework governing bidirectional exchange, shared services, or secondary data use. Operation of governance and interoperability arrangements in practice In practice, governance arrangements operate through negotiated and capacity-dependent processes rather than enforced rules. Empirical studies, technical reports, and institutional assessments indicate that governance and interoperability arrangements operate unevenly across system levels. Table 3 contrasts formally specified governance and interoperability arrangements with observed implementation practices across national, subnational, and facility levels. Table 3. Operation of governance and interoperability arrangements in practice across system levels Governance or interoperability domain What is formally specified What is observed in practice Level where gaps are evident Evidence reported Inter-agency coordination Inter-agency committees and TWGs mandated by MoH and GHS policies Irregular convening; limited authority to align systems National (Ministry of Health, 2022), (Ghana Health Service, [ 18 ]), (GIZ, [ 19 ]) System integration DHIMS2 designated as national repository; automation permitted Parallel systems; manual workarounds; partial or one-way data flows National and subnational Abotsi et al., [ 2 ], (Ghana Health Service, [ 17 ]) Enforcement of standards Compliance with e-GIF and sector standards required Legacy and donor systems bypass standards National (Government of Ghana, [ 20 ]), (Ministry of Health, 2022) Subnational governance Regional and district oversight structures defined Variable leadership ownership; weak technical capacity Subnational Abotsi et al., [ 2 ], [ 27 ] Facility-level EMR integration EMRs expected to support reporting and continuity Facility-specific systems not interoperable Facility Achampong, [ 3 ], [ 44 ] Data protection enforcement Registration and compliance mandated by law Compliance uneven; enforcement largely complaint-driven Cross-sectoral (Parliament of Ghana, [ 47 ]), (Cyber Security Authority, [ 15 ]) Cybersecurity governance Health entities classified as critical infrastructure Low cybersecurity maturity; weak safeguards Facility and institutional (Cyber Security Authority, [ 15 ]), (IIPGH, [ 24 ]) Open in a new tab The study found that, although formal coordination structures are established at the national level, these mechanisms convene irregularly and lack authority to align system design, procurement decisions, or partner-supported investments. The District Health Information Management System-2 (DHIMS-2) is Ghana’s primary system for routine health data collection and management and serves as the national central repository, alongside other platforms such as the Ghana Health Information Management System (GHIMS), with operational guidance permitting automation from selected digital health systems [ 51 ]. In practice, parallel platforms, manual data entry, and partial data flows persist across national and subnational levels. Facility-level transactional systems and electronic medical records frequently operate independently, with linkage limited to aggregate reporting [ 3 , 44 ]. At the subnational level, evidence indicates substantial variability in leadership ownership, technical capacity, and oversight effectiveness, contributing to continued reliance on manual workarounds and parallel reporting systems [ 10 , 27 ]. At the facility level, donor- and project-driven digital tools are often deployed independently of national architectures, reinforcing fragmentation [ 49 ]. Compliance with data protection and cybersecurity requirements is uneven, with limited documentation of routine audits or corrective enforcement actions, despite statutory obligations (Cyber Security Authority, [ 15 ]). Persistent governance and interoperability gaps and system-level consequences Fragmentation reflects structural governance failures rather than isolated implementation problems. The review identifies persistent governance and interoperability gaps across system levels. A primary gap is the fragmentation of institutional mandates across policy stewardship, system operations, regulation, and standard-setting, without a binding mechanism to align authority or enforce coordination. Weak enforcement mechanisms further exacerbate fragmentation, as policies and frameworks lack mechanisms for compliance monitoring, certification, or sanctions. Donor-driven and project-based implementations are repeatedly identified as contributing to system proliferation, with limited integration planning and weak alignment with national architectures (GIZ, [ 19 ]). Capacity constraints at subnational and facility levels further reinforce reliance on manual processes and parallel systems. These governance gaps are associated with system-level consequences, including duplicated data collection, restricted data sharing, challenges in scaling digital health initiatives, uneven application of data protection safeguards, and increased exposure to cybersecurity risks. Collectively, the evidence indicates that fragmentation is a predictable outcome of governance arrangements that emphasize guidance over enforcement rather than an absence of strategies or technologies. Table 4 synthesizes the principal governance and interoperability gaps identified in the reviewed evidence and links them to their reported system-level consequences. The table shows how fragmented mandates, weak enforcement, donor-driven implementations, and limited subnational capacity contribute to persistent fragmentation, data duplication, and trust and security risks within Ghana’s digital health system. Table 4. Drivers of persistent governance and interoperability gaps and associated system-level consequences Reported gap or constraint How it is described in the evidence Level where it occurs Reported system-level consequences Sources reporting this Fragmented institutional mandates Overlapping authority across MoH, GHS, NHIA, NITA, and autonomous agencies without a binding coordinator National Parallel systems; weak alignment of investments (Ministry of Health Ghana, [ 36 ]), (Ministry of Health, [ 35 ]), [ 3 ] Weak enforcement mechanisms Policies and frameworks exist but lack sanctions or compliance monitoring National Non-compliance with standards; persistence of siloed systems (Government of Ghana, [ 20 ]), (Ghana Health Service, [ 18 ]) Donor-driven and project-based implementations Digital systems introduced through vertical projects with limited integration planning National and subnational Sustainability risks; duplication of platforms (GIZ, [ 19 ]; Ministry of Health, [ 35 ]) Limited subnational technical capacity District and facility levels lack ICT skills and infrastructure Subnational Manual workarounds; inconsistent data quality Abotsi et al., [ 2 ], [ 27 ] Absence of binding interoperability standards Interoperability described as a goal rather than a requirement National One-way or non-existent data exchange (Achampong, [ 3 ]; Ministry of Health Ghana, [ 36 ]) Weak cybersecurity implementation Low cybersecurity maturity despite legal frameworks Facility and institutional Reduced trust; exposure to data breaches (Cyber Security Authority, [ 15 ]), (IIPGH, [ 24 ]) Unclear data ownership and reuse rules Legal protections exist, but operational guidance is limited Cross-sectoral Hesitation to share data; restricted secondary use (Norman et al., [ 40 ]; Parliament of Ghana, [ 47 ]) Open in a new tab Discussion This scoping review examined how the integration of Ghana’s national digital health systems is governed, focusing on institutional authority, regulatory frameworks, and interoperability arrangements, and on how these operate in practice. The findings show that Ghana’s persistent digital health fragmentation is not primarily a consequence of policy absence or technological immaturity, but of a governance execution gap in which authority, enforcement, and accountability remain misaligned. This distinction is central to understanding why repeated strategies and technical frameworks have not been translated into sustained system integration. A core contribution of this review is to demonstrate that governance arrangements for digital health in Ghana are dense but weakly binding, as documented in previous literature [ 6 ]. Authority over policy direction, system operations, regulation, and standard-setting is distributed across multiple institutions, each exercising legitimate but partial mandates. In practice, no single actor is empowered to compel alignment across systems, agencies, or investments. As a result, coordination relies on negotiation, informal cooperation, or project-specific arrangements rather than enforceable rules. Similar patterns have been noted in other LMIC settings, where fragmented authority and weak enforcement limit the effectiveness of national digital health strategies despite strong policy intent [ 45 , 52 ]. The review further highlights that interoperability is treated primarily as a strategic aspiration rather than as a governance instrument. Although policies and technical frameworks consistently emphasize interoperability, they do not operationalize it as a mandatory condition for system procurement, deployment, or continuation. This distinction has practical consequences. Where interoperability is not enforced through procurement rules, certification processes, or compliance monitoring, systems can remain formally aligned with policy objectives while operating in isolation [ 7 , 28 ]. The persistence of parallel platforms and partial data flows in Ghana illustrates how aspirational framing allows fragmentation to coexist with apparent policy coherence. Understanding why governance and interoperability arrangements operate unevenly in practice requires attention to implementation realities and incentives. Coordination mechanisms lack the authority to align donor-supported and autonomous systems, whereas vertical programmes prioritize short-term reporting and service-delivery objectives over long-term system coherence. At subnational and facility levels, capacity constraints encourage pragmatic adaptations, including manual workarounds and parallel reporting systems. In this context, governance frameworks are applied selectively, shaped by available resources, institutional incentives, and local constraints rather than by formal design. Fragmentation is therefore not an anomaly but a predictable outcome of governance [ 38 ]. The uneven implementation of data protection and cybersecurity obligations further illustrates this execution gap. Ghana has enacted concrete cross-sectoral legislation relevant to digital health, yet enforcement within the health sector remains variable. The evidence suggests that compliance is often awareness-driven and reactive, rather than audit-based and systematic. These weaknesses are not isolated technical failures but reflect broader limitations in regulatory enforcement capacity, which also constrain interoperability and coordination. As digital health systems expand and data volumes increase, these governance weaknesses carry implications for trust, system sustainability, and exposure to security risks. While this review focuses on Ghana, the findings have relevance beyond a single country case. Many LMICs face similar combinations of policy proliferation, donor-driven digital investments, and fragmented institutional authority. Ghana’s experience illustrates how early adoption and strategy density do not automatically translate into integration without enforceable governance mechanisms. Comparative experience from other settings suggests that countries achieving higher levels of digital health integration have moved toward rule-based governance models, in which interoperability standards are mandatory, compliance is monitored, and system alignment is enforced ([ 21 ]; World Bank, [ 56 ]). These observations should be interpreted as contextual contrasts rather than direct comparisons, but they underscore the importance of governance execution in shaping digital health outcomes. Limitations Several limitations should be noted. As a scoping review, this study did not assess the quality of individual sources or evaluate the effectiveness of specific digital health systems. The synthesis relied on publicly available literature, which may underrepresent informal practices or unpublished enforcement activities. Nonetheless, the convergence of findings across peer-reviewed studies, policy documents, and technical reports strengthens confidence in the identified governance patterns. In summary, this review reframes Ghana’s digital health integration challenge as one of execution rather than intent. By consolidating dispersed evidence on governance arrangements and their operational practices, the study shifts attention from further strategy development toward questions of authority, enforcement, and accountability. Addressing these dimensions is likely to be critical not only for Ghana but also for other countries seeking to move from fragmented digital health initiatives toward integrated, trusted, and sustainable health information infrastructures. Conclusion This scoping review shows that the integration of Ghana’s national digital health systems is governed through a dispersed set of institutions, policies, and technical frameworks that articulate strong intent but exert limited control over system behaviour. Governance, regulatory, and interoperability arrangements exist, yet they function primarily through coordination and guidance rather than through enforceable rules, resulting in uneven implementation across national, subnational, and facility levels. The persistence of fragmentation is therefore not accidental but structural, reflecting how authority, incentives, and enforcement are configured rather than the absence of strategies or technologies. The central implication is that digital health integration in Ghana is constrained less by technical capacity than by governance execution. Without a shift toward rule-based coordination in which interoperability, data protection, and cybersecurity are treated as mandatory system requirements, further digital investment risks reinforcing fragmentation rather than resolving it. Implications for policy and practice The policy and practice implications of this review should be interpreted in light of the nature of the available evidence, which is dominated by policy documents, regulatory instruments, and institutional and technical reports, with a smaller number of empirical studies. Accordingly, the implications outlined here are not intended as prescriptive or causal claims, but as system-level insights derived from synthesizing how digital health systems integration is currently governed in Ghana, situated within the broader state of knowledge on digital health governance. A central implication for policy is that fragmentation in Ghana’s digital health landscape is less a consequence of policy absence than of weak governance execution. Across the reviewed sources, integration and interoperability are consistently articulated as strategic objectives, yet they are rarely embedded in enforceable rules, binding standards, or compliance mechanisms. This pattern mirrors broader international experience, in which voluntary coordination and strategy-led alignment have proven insufficient to counteract parallel system development and institutional siloing [ 12 , 50 ]. For policymakers, this implies a shift from aspirational coordination toward rule-based governance, in which interoperability, data governance, and cybersecurity requirements are operationalized through procurement conditions, system approval processes, and regulatory oversight. The evidence also highlights the importance of clarifying and consolidating institutional authority for digital health governance. While multiple actors hold legitimate mandates across the health, ICT, data protection, and cybersecurity domains, the dispersion of authority without a clearly empowered stewardship body constrains the state’s capacity to align system design, enforce standards, and resolve cross-institutional tensions. Policy experience from comparable settings suggests that effective integration is more likely where a designated authority possesses not only coordination responsibilities but also formal decision-making and enforcement powers over system deployment and compliance with national frameworks [ 13 , 23 , 39 ]. At the level of practice, the reviewed evidence illustrates how governance arrangements shape day-to-day system use and integration. As observed in previous studies [ 31 , 37 ], weak enforcement and unclear mandates lead to operational practices such as parallel reporting systems, partial data exchange, and reliance on manual workarounds. These practices are not merely technical inefficiencies but rational responses to governance environments in which compliance with integration standards is optional or inconsistently applied. Strengthening integration in practice, therefore, requires aligning national policies with subnational and facility-level governance capacity, including sustained technical support, clear accountability structures, and realistic implementation expectations. The findings further point to the growing salience of data protection and cybersecurity governance as integral components of digital health integration. As systems become more interconnected, gaps in security oversight and data governance can undermine trust and restrict data sharing, even where technical interoperability exists [ 5 , 29 , 37 ]. From a policy perspective, this implies that integration strategies must treat cybersecurity and data protection not as ancillary considerations, but as core governance conditions for sustainable system integration. Overall, the implications presented here reflect a synthesis of the reviewed evidence, interpreted through established understandings of digital health systems governance. They suggest that progress toward integrated digital health systems in Ghana will depend less on additional strategies or pilots and more on strengthening enforceable governance arrangements that align institutional authority, regulatory instruments, and implementation practices across the health system. Supplementary Information Below is the link to the electronic supplementary material. Supplementary Material 1 (66.8KB, pdf) Supplementary Material 2 (223.2KB, pdf) Acknowledgements The authors acknowledge the institutions and organizations whose publicly available reports and policy documents informed this review. Abbreviation API Application Programming Interface CSA Cyber Security Authority (Ghana) DHIMS-2 District Health Information Management System version 2 e-GIF e-Government Interoperability Framework HER Electronic Health Record EMR Electronic Medical Record GHS Ghana Health Service GHIMS Ghana Health Information Management System HIS Health Information System HISSP Health Information System Strategic Plan LMICs Low- and Middle-Income Countries mHealth Mobile Health MoH Ministry of Health NHIA National Health Insurance Authority NHIS National Health Insurance Scheme NITA National Information Technology Agency SOP Standard Operating Procedure TWG Technical Working Group Author contributions SN conceptualized the study, conducted the literature search, data charting, synthesis, and drafted the manuscript. ANO and DB independently screened studies, contributed to data extraction and interpretation, and reviewed the manuscript. RAA provided senior oversight, contributed to study design refinement, interpretation of findings, and critical revision of the manuscript. All authors read and approved the final manuscript. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Data availability All data analyzed in this study are derived from publicly available sources. The list of included sources and the search strategies are provided in the supplementary materials. No new datasets were generated or analyzed during the current study. Declarations Ethics approval and consent to participate Ethical approval was not required for this study. The research was based exclusively on analysis of publicly available literature, policy documents, and institutional reports and did not involve human participants, individual-level data, or identifiable personal information. Consent for publication Not applicable. 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Supplementary Materials Supplementary Material 1 (66.8KB, pdf) Supplementary Material 2 (223.2KB, pdf) Data Availability Statement All data analyzed in this study are derived from publicly available sources. The list of included sources and the search strategies are provided in the supplementary materials. No new datasets were generated or analyzed during the current study. 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