Coping with ill-health while lacking access to health care: Acceptability of health service provision in rural Malawi - a qualitative study.

Background: Large parts of Malawi`s population lack access to health care. A high burden of disease, chronic poverty, and a growing population accelerate the need for extending and improving health care. One region that is struggling with service provision is Malawi´s rural district Phalombe. In addition to adequate resources, acceptability of service provision and productive patient-provider engagements are crucial determinants of health-seeking behaviour.

Objective: This study aimed to better understand the interdependencies between acceptability, patient-provider engagement, and health-seeking behaviour in Phalombe. By targeting health care providers and community members, different perspectives were assessed and triangulated.

Methods: Following a qualitative approach, group interviews were conducted with community members of three rural villages (n = 21) in Phalombe. Semi-structured interviews (n = 2) and a group interview among management staff (n = 3) provided insight into experiences of health care providers.

Results: Community members perceived health care providers' behaviour as disrespectful, resulting in power gaps between patients and providers. Providers blamed community members' cultural beliefs and lack of awareness regarding health care as barriers to seek formal services. Systemic shortcomings diminished community members' trust in service provision, while increasing frustration among providers and thus impacting patient-provider engagement. Due to insufficient resources, lack of acceptability and trust in receiving adequate services, potential patients turned into non-users of health care.

Conclusions: A patient-centred approach is needed that empowers communities by involving them in health care planning, in facility management, and by raising awareness towards health issues. Trainings for providers need to focus on improving communication and building trustful patient-provider interactions. Yet, without addressing systemic constraints, providers' frustration and patients' lack of trust in service provision will remain and impact their health-seeking behaviour. Thus, further budget needs to be allocated to Malawi's health care sector in order to provide resources needed.