Research on the patterns and mechanisms of institutional change and their linked outcomes under health shocks is lacking in forest management literature. Using Ghana as a sub-Saharan African case and guided by the structures-processes framework, we analyzed five decades of institutional change patterns and mechanisms and their linked outcomes under health shocks to address this gap. Data were drawn from 24 key informant interviews, 16 focus groups, 4 expert interviews, and 10 policy documents. The pre-2016 period, marked by Ebola and Mpox risks, witnessed institutional reinforcement, expansion, and critical junctures that promoted forest conservation and health shock mitigation. By contrast, COVID-19 triggered institutional layering in 2022, facilitating logging and mining in biodiversity hotspots with negative ecological and economic outcomes. This study extends institutional change theorization by showing that institutional change converges into patterned trajectories under health shocks. Future research should clarify the actor constellations that shape forest management institutional compliance.