Healthcare systems in many developing countries are fraught with a multiplicity of challenges that have over the years produced unsatisfactory outcomes [32, 41, 43, 55]. By healthcare system, we mean ‘the organisation and interrelation of the resources, be they human, physical and institutional that are directly implicated in healthcare’ ([32], p. 3). In Ghana, researchers have identified numerous deficiencies in the system, including rising unmet healthcare demands and increased out-of-pocket healthcare costs for users [32]. Saleh ([56], p. 3) adds that ‘although in many cases, quantity and access have increased, quality of care remains problematic’. Consequently, healthcare systems in Ghana and many sub-Saharan African countries have gradually been reinvented, particularly by detaching from colonial structures to accommodate modern demands and satisfy the current market-driven orientation [32]. Such policy innovations have cultivated new healthcare systems that are pluralistic and relatively more efficient [32, 56]. In Ghana, developments such as the establishment of social health insurance schemes (e.g., the National Health Insurance Scheme, NHIS), expansion of recruitment and training of health personnel, and the provision of modern healthcare facilities are common [7, 32]. Additionally, initiation of social welfare policies such as the Livelihood Empowerment against Poverty (LEAP) programme and free maternal healthcare policy are considered critical in protecting the health-related well-being of vulnerable groups in the country [23, 42, 50, 52, 53]. Key health indicators such as under-five mortality rate (a decline from 111 per 1000 live births in 2003 to 48 in 2018); maternal mortality (a decline of between 610 and 720 per 100,000 live births in 1990 to 308 in 2017); and increased life expectancy (from 57 in 2000 to 63 in 2016) are indicative of significant improvements in health outcomes in recent years [56, 61, 63].
However, a critical, yet unanswered question is whether the public is satisfied with the milestones achieved by the health system so far. This question is important because recent trends point to a changing demographic and epidemiological profile (e.g., rising non-communicable diseases alongside various infectious diseases) that are putting new demands on the healthcare system, which needs to be even more responsive [6, 12, 33, 34, 56]. Regrettably, most studies of healthcare-system-satisfaction globally have focused on patients, with a few on the public view [48]. This is also the situation in Ghana where existing research is dominated by the responses of health professionals and patients, perhaps due to under theorisation of views and perceptions of the public [2, 13, 49]. Moreover, empirical studies on public satisfaction with healthcare systems have predominantly been in high-income countries [36]. Thus, public opinion is not holistically understood and considered when shaping health services in developing and non-western countries [18, 36].
Ghana’s health system: an overview
In line with Ghana’s decentralisation policy, which came into being in 1988, the health system of Ghana is highly decentralised. The Ministry of Health (MoH), together with sub-agencies such as Ghana Health Services (GHS) and the National Health Insurance Authority (NHIA), manage the health system of Ghana [32, 45, 56]. The MoH mainly deals with the policy and regulatory aspects of the system, while the GHS manages the delivery of different kinds of health services. GHS has the mandate to promote access to health services at the community, sub-district, district, and regional levels [51]. The NHIA oversees the National Health Insurance Scheme (NHIS)—a pro-poor financial buffer scheme—and other private health insurance schemes [32, 56].
Ghana’s health system is pluralistic in terms of the types of services offered. Both orthodox and traditional medical services are practised under various regulatory frameworks. The traditional medical services primarily comprise herbal remedies and spiritual healing [1]. Given its high patronage and importance in healthcare delivery, traditional medical practices were formalised in 2012 [1]. Notwithstanding, many householders still rely on unapproved herbal and spiritual care due to the poor integration of traditional medical services into the formal healthcare system [56]. The public sector contributes more than half of all healthcare expenditure on infrastructure, service provision, and training and recruitment of health personnel [32]. Private sector institutions, such as mission health services, provide significant supplementary and complimentary services [32].
With regard to human resources, Ghana is relatively well-serviced compared to countries with similar economic conditions [56, 60]. However, when benchmarked against international standards, the country is under-resourced. For instance, its average number of essential healthcare workers per 1000 population is 1.24 compared to the standard of 2.02 to 2.54 worldwide, and some 40% of these staff are non-clinical staff [56]. Notwithstanding, recent development plans have focused on improving ‘the health outcomes of the people’; by offering ‘financial protection’; and by ensuring ‘that the system is responsive, efficient, equitable, and sustainable’ ([56], p. 31).
Ghana’s healthcare system is now facing a double burden of disease with the rapid rise in non-communicable diseases (e.gs., hypertension and diabetes) alongside prevalent communicable diseases such as malaria [10, 33]. One of the key challenges facing the health system in Ghana is equity—ensuring that people in the same circumstances are treated the same [30]. Inequity in access to healthcare in Ghana arises from a multiplicity of factors, including the uneven rural-urban distribution of health resources, poverty, gender, and geographical location [26, 38].
Aim of the study
This study adopts a social ecological lens, which is explained below, to explore how individual characteristics and their perceptions and ideological convictions, relating to various meso- and macro-level factors, affect the extent to which the public is satisfied or dissatisfied with the healthcare system in Ghana. Although research in this area is still evolving, examining public satisfaction with a healthcare system is considered one of the critical avenues for evaluating its performance and offering alternatives for system improvement [59]. After all, healthcare and health policy are meant to promote the well-being of people, and thus, their views, experiences, and expectations are critical to sustaining the system [36]. Satisfaction with the healthcare system in this study refers to whether the ordinary person is content with the overall characteristics of extant services, policies, institutions, personnel, facilities, and all factors related to public healthcare delivery. In contrast, the discontent of the ordinary person is counted as dissatisfaction with the healthcare system [27, 59].
Conceptual framework and literature review
The study uses the social ecological model to offer a broader understanding of the correlates and perceptions of public satisfaction with the healthcare system [44]. The social ecological model posits that individuals are embedded in five multi-level domains that interactively shape the conditions of their lives as well as their expectations, standards, values, attitudes, behaviours and perceptions of their relationships with their environments [31, 57]. These multi-level domains comprise intrapersonal, interpersonal, institutional or organisation, community characteristics, and public policy environment domains [44]. Individual expectations and standards are inextricably connected with prevailing personal and ecological factors regarding satisfaction with the healthcare system [41]. In the context of this study, the five multi-level domains of the model are conceptualised into four (see Fig. 1), which are presented below relative to the phenomenon of public satisfaction with the healthcare system. We combined the domains on organisation and public policy domains because they concern institutional arrangements and policies that shape healthcare delivery.
The intrapersonal domain relates to existing characteristics such as age, sex, skills, knowledge, attitude, values and standards, and other demographic factors that predispose individuals to perceive a phenomenon positively or negatively, including healthcare systems [14, 28, 59]. For example, more educated persons (e.g. university graduates) are less likely to be satisfied with a health system than the less educated, according to research [19]. However, the rating of satisfaction with a health system also depends on individual needs or self-interest [36]. Andersen et al. [14] argues that these needs relate to the state of a person’s health and well-being which fundamentally determine how and whether they engage with the healthcare system [19]. People with poor health and those who are disconsolate are less likely to be content with the health system compared to those in good health due to outcome-based perception of the quality of services offered [2, 13, 48, 59].
According to the social ecological framework, individual perceptions are influenced by characteristics of the social environment in which they occur i.e., interpersonal domain. Factors such as social networks, social support, and quality of social relationships are essential to how people rate a phenomenon. People tend to evaluate their satisfaction with the healthcare system by comparing it with others in their social networks to ensure that their opinions are ‘correct’ [41]. In the literature on social capital (SC)—the social resources that are embedded in different kinds of social relationships—the role of social relationships in providing sufficient health services and thereby determining satisfaction with the health system is conceptualised as a social influence [9, 35, 41]. The interpersonal domain also connects to the perception of receptiveness of service providers. Attitudes of health personnel—particularly physicians and nurses—can influence the degree to which people are satisfied with the health services available to them [2, 55]. Poor attitudes of health personnel can adversely affect public satisfaction, but little is known about the actual extent of the problem in Ghana [2, 3].
The community domain in this study refers to a geographical and cognitive sense entity. It thus comprises factors such as whether a person lives in a rural or urban community, the duration of living in that community (which determines the physical and psychological bonds they form), cultural norms, and religious beliefs and groups. For instance, a study in mainland China found that rural residents tend to be more satisfied with the health care system than urban residents due to less pressure on facilities and services [64].
The organisational and public policy domain, as adapted for this study, focuses on ideational positions, attitudes, and perceptions on public policy and institutional arrangements aimed at improving the healthcare system, promoting health and well-being, and ‘policies that allocate programmatic resources’ such as welfare interventions and health insurance programmes ([44], p. 365). The effectiveness of public policies and institutional arrangements depend on how they are aligned with community characteristics, people’s expectations, and interpersonal facets of a community [44]. In view of these, factors such as trust, political perspectives, and welfare attitudes (e.gs., possession of egalitarian ideology) can affect satisfaction with a healthcare system, although these factors are rarely examined in extant research [27, 36, 59]. For instance, satisfaction with the health system is higher in places with functioning social insurance schemes where out-of-pocket payments for health services are low [20, 48, 62]. Bhatia et al. [18] argue that people who share similar ideological orientation as a given phenomenon or policy are likely to possess favourable opinions about the policies [18, 27, 48, 59].