The effects of affordability and quality of care on utilization of primary healthcare among rural residents in Twifo Ati-Morkwaa district, Ghana: a qualitative study

This qualitative study examines how affordability and quality of care influence the utilization of primary healthcare (PHC) services among rural residents in the Twifo Ati-Morkwaa District, Ghana. While Ghana has implemented policies such as CHPS and NHIS to improve access, subjective experiences of rural residents regarding total costs of care and perceived quality remain underexplored. We conducted a qualitative cross-sectional study between April and September 2024 using purposive and snowball sampling. Ten gender-segregated focus group discussions (FGDs; n = 90 residents) and six in-depth interviews (IDIs) with PHC providers were conducted. Data were collected in Twi, transcribed and translated into English, and analyzed using an inductive–deductive thematic approach guided by Andersen’s Behavioral Model and Penchansky & Thomas’ access framework. Rigor was enhanced through triangulation and member checking. Three inter-related themes emerged: (1) Affordability; transportation and indirect costs substantially increased total cost of care despite NHIS coverage for direct services; (2) Quality of care; staff attitudes, communication, and drug availability shaped perceived quality; (3) Satisfaction; wellness after care and willingness to return mediated utilization, but negative interpersonal experiences led some residents to self-medicate or use traditional remedies. Providers acknowledged resource and workload constraints that influenced behavior and service quality. These district-specific qualitative findings may inform local policy and support strategies in similar rural contexts by highlighting the importance of addressing indirect costs and interpersonal quality alongside insurance coverage. Recommendations include training staff in patient-centered communication to enhance interpersonal interactions, optimizing patient flow to reduce waiting times, and engaging community health volunteers to support outreach and follow-up activities.