Factors influencing the use of public and private health care facilities among poor older people in rural Ghana

  • Williams Agyemang-DuahEmail author
  • Charles Peprah
  • Prince Peprah
Original Article



The choice of a particular health care facility is premised on certain factors which remain largely unknown in rural settings in Ghana. The purpose of this study was to explore issues influencing public and private health care facilities use among poor older people in rural Ghana.


In-depth interviews and focus group discussions were conducted with 30 poor older persons, 15 caregivers, and 15 formal health care providers in the Atwima Nwabiagya District of the Ashanti Region of Ghana. A thematic analytical framework was used to analyze the data, which was then presented based on an a posteriori inductive reduction approach.


Three key public health care facility use factors were identified: health insurance acceptance, perceived service affordability, and availability of well-trained professionals. For private health care facilities, five main use factors were found: distance and proximity, good interpersonal relationships, good quality health services, service responsiveness, and logistics availability.


The findings of this study have implications for addressing attitudinal problems existing mainly in public health care facilities in Ghana. It also calls for policy intervention toward equitable access to public and private health facilities, especially for poor older persons.


Public health facility Private health facility Poor older people Rural Ghana Qualitative 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Furthermore, the Committee on Human Research Publication and Ethics (CHRPE), School of Medical Sciences, Kwame Nkrumah University of Science and Technology and Komfo Anokye Teaching Hospital, Kumasi, Ghana provided approval for this study (ref.: CHRPE/AP/311/18).

Informed consent

Informed consent was obtained from the study respondents before data collection began. They were assured that their participation in the study was voluntary and that they were free to opt out at any time.


  1. Ager A, Pepper K (2005) Patterns of health service utilization and perceptions of needs and services in rural Orissa. Health Policy Plan 20:176–184CrossRefGoogle Scholar
  2. Agha S, Do M (2009) The quality of family planning services and client satisfaction in the public and private sectors in Kenya. Int J Qual Health Care 21:87–96CrossRefGoogle Scholar
  3. Agyemang-Duah W, Mensah CM, Peprah P, Arthur F, Abalo EM (2018) Facilitators of and barriers to the use of healthcare services from a user and provider perspective in Ejisu-Juaben municipality, Ghana. J Public Health.
  4. Angen MJ (2000) Evaluating interpretive inquiry: reviewing the validity debate and opening the dialogue. Qual Health Res 10:378–395CrossRefGoogle Scholar
  5. Awoke MA, Negin J, Moller J, Farell P, Yawson AE, Biritwum RB, Kowal P (2017) Predictors of public and private healthcare utilization and associated health system responsiveness among older adults in Ghana. Glob Health Action 10:1301723CrossRefGoogle Scholar
  6. Barbour RS (2001) Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? BMJ 322(7294):1115–1117CrossRefGoogle Scholar
  7. Barua K, Borah M, Deka C, Kakati R (2017) Morbidity pattern and health-seeking behavior of elderly in urban slums: a cross-sectional study in Assam, India. J Family Med Prim Care 6:345–350CrossRefGoogle Scholar
  8. Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D (2012) Comparative performance of private and public healthcare systems in low- and middle-income countries: a systematic review. PLoS Med 9:e1001244CrossRefGoogle Scholar
  9. Bhat S, Kumar S (2017) Study on health care seeking behaviour among elderly in rural area. Int J Med Sci Public Health 6:350–352CrossRefGoogle Scholar
  10. Bitran RA (2011) Private health sector assessment in Ghana. World Bank Publications, Washington, DCGoogle Scholar
  11. Blanchet NJ, Fink G, Osei-Akoto I (2012) The effect of Ghana’s national health insurance scheme on health care utilisation. Ghana Med J 46:76–84Google Scholar
  12. Braun V, Clarke V (2006) Using thematic analysis in psychology. Qual Res Psychol 3(2):77–101CrossRefGoogle Scholar
  13. Creswell JW (2014) Research design: qualitative, quantitative, and mixed methods approaches, 4th edn. Sage, LondonGoogle Scholar
  14. Denscombe M (2010) The good research guide for small-scale social research projects, 4th edn. Open University Press, EnglandGoogle Scholar
  15. DiClemente RJ, Salazar FL, Crosby RA (2011) Health behavior theory for public health: principles, foundations, and applications. Jones & Bartlett Learning, Burlington, MAGoogle Scholar
  16. Ghana National Health Insurance Authority (NHIA) (2013) Annual report of the National Health Insurance Scheme of Ghana, 2012. NHIA, GhanaGoogle Scholar
  17. Glaser BG, Strauss AL (1967) The discovery of grounded theory: strategies for qualitative research. Aldine, ChicagoGoogle Scholar
  18. Government of Ghana (2012) Medium-term National Development Policy Framework: Ghana Shared Growth and Development Agenda (GSGDA), 2010–2013. National Development Planning Commission (NDPC), AccraGoogle Scholar
  19. Guba EG, Lincoln YS (1994) Competing paradigms in qualitative research. In: Denzin NK, Lincoln YS (eds) The SAGE handbook of qualitative research. Sage, Thousand Oaks, CA, pp 105–117Google Scholar
  20. He W, Goodkind D, Kowal P (2016) An aging world: 2015. International Population Reports, P95/16-1. U.S. Census Bureau, Washington, DCGoogle Scholar
  21. Jehu-Appiah C, Sekidde S, Adjuik M, Akazili J, Almeida SD, Nyonator F, Baltussen R, Asbu EZ, Kirigia JM (2014) Ownership and technical efficiency of hospitals: evidence from Ghana using data envelopment analysis. Cost Eff Resour Alloc 12(1):9CrossRefGoogle Scholar
  22. Karkee R, Kadariya J (2013) Choice of health-care facility after introduction of free essential health services in Nepal. WHO South East Asia J Public Health 2:96–100CrossRefGoogle Scholar
  23. Kowal P, Byles JE (2015) 900 million and counting. Epidemiologic data for demographic and policy transitions. Popul Horizons 12:68–76CrossRefGoogle Scholar
  24. Kusi A, Enemark U, Hansen KS, Asante FA (2015) Refusal to enrol in Ghana’s National Health Insurance Scheme: is affordability the problem? Int J Equity Health 14(1):2CrossRefGoogle Scholar
  25. Lagarde M, Palmer N (2008) The impact of user fees on health service utilization in low- and middle-income countries: how strong is the evidence? Bull World Health Organ 86:839–848CrossRefGoogle Scholar
  26. Lasch KE, Marquis P, Vigneux M, Abetz L, Arnould B, Bayliss M, Crawford B, Rosa K (2010) PRO development: rigorous qualitative research as the crucial foundation. Qual Life Res 19:1087–1096CrossRefGoogle Scholar
  27. Nabyonga Orem J, Mugisha F, Kirunga C, Macq J, Criel B (2011) Abolition of user fees: the Uganda paradox. Health Policy Plan 26:ii41–ii51CrossRefGoogle Scholar
  28. Onwuegbuzie AJ, Leech NL, Collins KMT (2010) Innovative data collection strategies in qualitative research. Qual Rep 15:696–726Google Scholar
  29. Papadimitriou DB (2007) Economic perspectives on aging. The Levy Economics Institute of Bard College, Working Paper No. 500Google Scholar
  30. Peltzer K (2009) Patient experiences and health system responsiveness in South Africa. BMC Health Serv Res 9:117CrossRefGoogle Scholar
  31. Peltzer K, Phaswana-Mafuya N (2012) Patient experiences and health system responsiveness among older adults in South Africa. Glob Health Action 5:1–11Google Scholar
  32. Qian D, Lucas H, Chen J, Xu L, Zhang Y (2010) Determinants of the use of different types of health care provider in urban China: a tracer illness study of URTI. Health Policy 98:227–235. CrossRefGoogle Scholar
  33. Rao KD, Peters DH, Bandeen-Roche K (2006) Towards patient-centered health services in India—a scale to measure patient perceptions of quality. Int J Qual Health Care 18:414–421CrossRefGoogle Scholar
  34. Ratnasingham S, Cairney J, Manson H, Rehm J, Lin E, Kurdyak P (2013) The burden of mental illness and addiction in Ontario. Can J Psychiatr 58(9):529–537CrossRefGoogle Scholar
  35. Ross LE, Vigod S, Wishart J, Waese M, Spence JD, Oliver J, Chambers J, Anderson S, Shields R (2015) Barriers and facilitators to primary care for people with mental health and/or substance use issues: a qualitative study. BMC Fam Pract 16:135CrossRefGoogle Scholar
  36. Saeed BI, Xicang Z, Yawson AE, Nguah SB, Nsowah-Nuamah NN (2015) Impact of socioeconomic status and medical conditions on health and healthcare utilization among aging Ghanaians. BMC Public Health 15:276CrossRefGoogle Scholar
  37. Spaan E, Mathijssen J, Tromp N, McBain F, ten Have A, Baltussen R (2012) The impact of health insurance in Africa and Asia: a systematic review. Bull World Health Organ 90:685–692CrossRefGoogle Scholar
  38. Thuan NTB, Lofgren C, Lindholm L, Chuc NTK (2008) Choice of healthcare facility following reform in Vietnam. BMC Health Serv Res 8:162CrossRefGoogle Scholar
  39. UNICEF and World Bank Group (2016) Ending extreme poverty: A focus on children. Briefing Note. New York, Geneva, Washington, DCGoogle Scholar
  40. United Nations, Department of Economic and Social Affairs, Population Division (2013) World population ageing 2013.. United Nations, New York, pp 9–11Google Scholar
  41. United Nations, Department of Economic and Social Affairs, Population Division (2015) World population prospects. The 2015 revision. United Nations, New YorkGoogle Scholar
  42. United Nations Development Programme (UNDP) (2004) Nepal human development report 2004. Empowerment and poverty reduction. UNDP, KathmanduCrossRefGoogle Scholar
  43. Vickers KA, Jolly KB, Greenfield SM (2006) Herbal medicine: women’s views, knowledge and interaction with doctors: a qualitative study. BMC Complement Altern Med 6:40CrossRefGoogle Scholar
  44. Witter S, Garshong B (2009) Something old or something new? Social health insurance in Ghana. BMC Int Health Hum Rights 9:20CrossRefGoogle Scholar
  45. World Health Organization (WHO) (2009) World health statistics. WHO, GenevaGoogle Scholar
  46. World Health Organization (WHO) (2011) Global health and ageing. National Institute on Aging; National Institutes of Health; U.S. Department of Health and Human Services; WHO, GenevaGoogle Scholar
  47. Yawson AE, Nimo KP, Biritwum RB (2013) Challenges of health care delivery at a municipal health facility under Ghana’s National Health Insurance Scheme. Postgrad Med J Ghana 2(2):56–64Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Williams Agyemang-Duah
    • 1
    • 2
    Email author
  • Charles Peprah
    • 1
  • Prince Peprah
    • 2
  1. 1.Department of PlanningKwame Nkrumah University of Science and TechnologyKumasiGhana
  2. 2.Department of Geography and Rural DevelopmentKwame Nkrumah University of Science and TechnologyKumasiGhana

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