Ghana is one of only several African countries to enact legislation and earmark financing for universal health insurance coverage for its entire population. Seven years into its implementation the Ghana National Health Insurance Scheme (NHIS) has made significant progress in transitioning to universal coverage, but faces significant fiscal and coverage challenges. This study reviews Ghana's health financing system with a special emphasis on its National Health Insurance Scheme. Such an assessment is important because Ghana is often considered a global 'good practice' in terms of earmarking significant amounts of its general revenues for health insurance coverage, providing formal coverage to its vulnerable population groups, and extending coverage by transitioning its existing community health insurance schemes into a national health insurance program. In addition to the global interest in the Ghana 'model', this review is timely in view of recent critiques of the system and questions about its financial sustainability. The study is also unique in terms of evaluating Ghana's NHIS in terms of basic health system goals of health outcomes, financial protection, consumer satisfaction, equity, efficiency, and financial sustainability. The strengths and weaknesses of Ghana's health financing system are assessed on the basis of these performance goals to provide the current health policy reform baseline. The assessment is also based on several new and updated sources of information on: total health spending, inputs, outcomes, household spending, and the macro economy. It also undertakes for the first time an extensive international benchmarking analysis; assesses the financial protection/equity of the system at both macro and micro levels; and, contains an extensive fiscal space analysis based on Ghana's new macroeconomic realities (i.e., the revaluation of Ghana's Gross Domestic Product (GDP) upward by some 60 percent in November 2010, making Ghana a lower middle income country). The study concludes with an assessment of potential structural and operational reform options to assure NHISs long-term efficacy and sustainability in the context of its future available fiscal space.