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

Objective 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. Methods A qualitative cross-sectional design using focus group discussions (FGDs) and in-depth interviews (IDIs) was employed. Ten FGDs (n = 90 participants; gender-separated) and six IDIs with healthcare providers were conducted across five communities. Data were collected in Twi, transcribed and translated, and analyzed thematically using a combined inductive-deductive approach guided by Andersen’s Behavioral Model and Penchansky & Thomas’ dimensions of access. Results 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. Conclusions Policies that focus solely on direct service fees (e.g., NHIS) may inadequately address barriers to PHC utilization if transport and interpersonal dimensions remain unaddressed. Recommendations include targeted strategies to reduce travel barriers (mobile clinics, community outreach), NHIS administrative reforms, and patient-centered communication training for frontline staff to enhance satisfaction and utilization among rural populations.