Global Public Health An International Journal for Research, Policy and Practice
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Trust matters: A narrative literature review of the role of trust in health care systems in sub-Saharan Africa Lise Rosendal Østergaard To cite this article: Lise Rosendal Østergaard (2015) Trust matters: A narrative literature review of the role of trust in health care systems in sub-Saharan Africa, Global Public Health, 10:9, 1046-1059, DOI: 10.1080/17441692.2015.1019538 To link to this article: http://dx.doi.org/10.1080/17441692.2015.1019538
Published online: 11 Mar 2015.
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Date: 06 November 2015, At: 02:40
Global Public Health, 2015 Vol. 10, No. 9, 1046–1059, http://dx.doi.org/10.1080/17441692.2015.1019538
Trust matters: A narrative literature review of the role of trust in health care systems in sub-Saharan Africa Lise Rosendal Østergaard*
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Department of Anthropology, Faculty of Social Sciences, University of Copenhagen, Copenhagen, Denmark (Received 20 February 2014; accepted 10 January 2015) This article makes a contribution to the debate about health service utilisation and the role of trust in fostering demand for health services in sub-Saharan Africa. It is framed as a narrative literature review based on a thematic analysis of nine empirical, qualitative studies. For the purposes of this article trust is defined as a voluntary course of action, which involves the optimistic expectation that the trustee will do no harm to the trustor and is increasingly perceived as an important influence on health system functioning. The article looks at trust issues in interpersonal, intergroup and institutional situations. The findings of the review point to four elements that are important for trust to develop in health sector relationships: the sensitive use of discretionary power by health workers, perceived empathy by patients of the health workers, the quality of medical care and workplace collegiality. When trust works in health sector encounters, it reduces the social complexity and inherent uneven distribution of power between clients and providers. The article concludes that understanding and supporting trust processes between patients and providers, as well as between co-workers and managers, will improve health sector collaboration and stimulate demand for health care services. Keywords: situations of trust; mistrust; ethnographic methods; narrative literature review; sub-Saharan Africa
Introduction ‘I give myself to you’. That is how trust is commonly translated in Moré, one of the languages spoken in Burkina Faso. During ethnographic fieldwork for a research project on how people in rural areas navigate the different health service options, the precariousness of trust in the public health care system kept coming up as a basic but far from trivial concern.1 It was the importance that health workers and patients ascribed to trust, which inspired this article. I argue that trust is an important factor in health care encounters and that a critical review of existing qualitative research can be a fruitful step in understanding the role trust plays in different types of health sector interactions. The article, therefore, reviews what the qualitative literature on trust in sub-Saharan Africa has to offer to the debate on health service demand. As people’s views are given more prominence in policy-making (Baltussen, Yé, Haddad, & Sauerborn, 2002), there is a growing interest in understanding which qualities patients find important and thus determine whether they develop trust in health care *Email: [email protected] © 2015 Taylor & Francis
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(Gilson, 2003, 2005; Ozawa & Walker, 2011; Thiede, 2005). A better understanding of not only actual but also perceived quality could contribute to improving demand for modern health services in low-income countries (Calnan, Rowe, & Entwistle, 2006; Gilson, 2005). In modern health care systems, the foundation for trust is that the patients in principle can have confidence in the health professionals’ expertise, conduct and practice because the sector is sanctioned by the state. In practice, lay people form knowledge about the health system through interaction with the front line health workers and experience with the material conditions and equipment of the health facility (Whyte, 2014). It is through these encounters that perceptions about quality are formed. There are two dominant theoretical answers to why trust matters to health care systems (Gilson, 2006). First, trust has the potential to improve therapeutic collaboration between provider and patient which is a precondition for the production of health (Gilson, 2003; Mechanic & Meyer, 2000). It is easier for the patient to disclose symptoms and to comply with treatment instructions if she or he has faith in the provider’s sense of confidentiality, competences and respect. The centrality of trust for therapeutic collaboration stems from the structurally uneven distribution of power between health professionals and patients. The provider has medical knowledge, clinical expertise and control over prescriptions and referrals, whereas the patient is in need of care (Grimen, 2009; Rowe & Calnan, 2006). Second, trust contributes to wider social value and civic engagement. The health sector not only produces health but also imaginaries of stateprovided social protection, because it is the state that has responsibility for regulating the sector (Duflo, 2010; Walt, 1994). This argument reflects broader concerns about the relationship between health care and citizenship, and is based on the assumption that if people receive quality care in the public services they seem to express greater trust in the state (Gilson, 2003). Thus a health system which is perceived as trustworthy has the potential to create a bond between the citizens and the state. This has implications for matters of equity as poor people in poor countries tend to express lower levels of trust in the public health sector (Gilson, 2006, p. 364). Ethnographic studies have shown how vulnerable and poor population groups are more likely to be subject to differential care by health providers in the public instutions and have fewer positive expectations of the health services (Andersen, 2004; Masquelier, 2001; Ridde, 2008). The failure of the public health sector to create the conditions for trusting relationships can thus further contribute to the marginalisation in society of vulnerable population groups. From the social science literature, trust appears not only as a powerful analytical concept but also as an evasive notion; fundamental questions remain on how trust can be defined, as well as how different actors view its core elements (Möllering, 2006). Goudge and Gilson (2005) define trust across cultural contexts as ‘a judgment in a situation of risk that the trustee will act in the best interests of the trustor, or at least in ways that will not be harmful to the trustor’ (p. 1440). In this sense trust is a voluntary course of action which is taken in a situation without full information, based on the optimistic expectation that the trustee will do no harm to the trustor (Giddens, 1990). Möllering (2006) argues that trust requires a ‘leap of faith’ where the trustor gives himself to the trustee in order to suspend the doubt that the trustor may have about the trustee’s intentions. Trust differs from adherence because it is based on an active choice made within the ambiguity of existing social relations. It is forward-looking, installing positive expectations, and thus differs from patient satisfaction which is based on past experience. According to Luhman (1979), the function of trust is to ‘reduce social complexity by going beyond available information and generalising expectations of behavior in that it replaces missing information with an internally guaranteed security’ (p. 93, cited in Misztal, 1996).
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1048 L.R. Østergaard A health care encounter can be a complex social situation. Here trust operates as a way of solving the problem of the power gap without eliminating it. The gap persists, but it becomes possible for the patient to act as if it were not there and to suspend the irreductible uncertainty of a medical encounter (Möllering, 2006, p. 6). In line with the previously mentioned observations from Burkina Faso, Geschiere (2013) argues that trust must be understood as a phenomenon which is ‘precarious and situational (never “ontological”)’ (p. xiii). The research field on the role of trust in the health sector is dominated by studies based on quantitative methods scrutinising the extent and distribution of trust as a predefined phenomenon across a population. In spite of the valuable contributions of this approach, it is not well suited to provide insights into how people make meaning of trust. The aim of qualitative research is to produce an understanding of people’s life worlds, what they hope for and how they deal with their vital problems such as obtaining quality health care (Whyte, 2002, p. 172). In her influential article on health care as a social institution, Gilson (2003) suggests that the health sector must be understood as ‘inherently relational’ (p. 1453), leading her to the conclusion that some of the challenges which the sector is exposed to are relational. Seen from this perspective, the quality of health sector relations becomes critical for the sector’s ability to produce health and civic engagement. Following that line of thought, the present review is based on qualitative studies using ethnographic methods such as in-depth interviews and focus groups in order to capture the local specificities which frame these relationships. The reviewed studies examine how trust is perceived and lived by health sector actors in three sets of relations: between patients and providers, between co-workers and finally as the trust that people can have in health institutions or in medical technologies. This framework has been identified through a content analysis of the selected studies. First, we will look at interpersonal relationships where trust grows out of personalised interactions, either between patient and provider or between people who work together. Second, we will look at examples of how people can develop a trusting relationship with an institution based on perceived quality, safety and cultural appropriateness of services provided, e.g., a private clinic compared to a public facility. Medical anthropologists have shown how people in societies with faltering public health services tend to place their hope for cure and care in private facilities, where they expect to be treated like a client rather than a simple patient (Samuelsen, 2004; Whyte, 2005). Third, examples of how trust can be based in an institution or a medical technology is discussed. This kind of trust is based on the patient’s faith in the efficacy of the technology itself rather than the provider administering it or the institution offering it, e.g., in the power of injections (Whyte, van der Geest, & Hardon, 2002). In the conclusion, we will see that four aspects appear to build or break trust in health sector encounters: sensitive use of discretionary power, perceived empathy, quality of medical care and workplace collegiality.
Methodology This article is framed as a narrative literature review. This method rather than a systematic literature review has been chosen because narrative reviews allow for the analytical integration of studies that differ in terms of methodology but which capture different perspectives of a social phenomenon (Samuelsen, Norgaard, & Østergaard, 2012). These studies would have been difficult to bring together within the rigorous design of systematic reviews (Green, Johnson, & Adams, 2006).
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The article draws on studies identified by the author assisted by a research librarian. We conducted a comprehensive search in six computerised databases: Web of Science, SCOPUS, Medline, FRANCIS, Anthropology Plus and Google Scholar. Different terms related to trust, health care, health workers and Africa were used. No period was specified, and articles published in English and French were included. In order to ensure a level of academic quality, the review comprises only peer-reviewed articles. An important subset of literature studies the role of trust in medical research trials (Geissler, 2014; Molyneux, Peshu, & Marsh, 2005), but these types of trust relations seem to have higher levels of uncertainty and different ethical stakes compared to patient–provider engagement, so they have not been included. Following these criteria, nine studies were selected. Table 1 provides the details of each study. There are at least two sets of limitations to the search strategy. First, it cannot be excluded that ethnographic studies are less rigorously indexed in databases than for example public health studies, thus some articles might be missing if they have been wrongly indexed. The chances have been minimised through a manual retrieval of the abstracts to scrutinise the literature lists for studies that did not appear in the database searches. Second, in order to have a manageable volume of material, books are not a part of this review, which is a weakness because some ethnographic studies are published in anthologies instead of as articles. A stepwise approach has been followed in the analytical work. After the selection of a body of literature, the first step was to identify the purpose and the perspective on trust of each study with the objective of seeing how the studies link together (Baumeister & Leary, 1997; Britten et al., 2002). Then the findings regarding the bases of trust of each paper were analysed using a thematic approach. Finally, the identified themes were sought and synthesised. As the context of the studies differs, a rigorous comparative analysis has not been attempted. Findings Empirically, eight of the reviewed articles are located in southern and eastern Africa, with the majority of the cases coming from urban or semi-urban localities, and two from exclusively rural settings. Analytically, the articles share a view on health care as a social institution in which trust must be analysed as a relational and context-specific phenomenon. Eight of the articles are actor-oriented, placing their interest in capturing the perspectives of different actors; one study is primarily system-oriented, looking at trust issues at the macro-level. All studies are explorative and designed to ask open-ended questions. Methodologically, they use detailed ethnographic accounts produced over an extensive period of time. Four of the studies were originally designed to study trust, but those which were not have drawn on large data-sets to conduct a focused analysis of trust aspects. Their retrospective interest in trust stems from the weight with which trust issues were raised by the informants. The studies use qualitative methodologies including observations, focusgroup discussions, in-depth interviews and document analysis. Some of the studies combine qualitative with quantitative methods, such as statistical analysis of selfadministered questionnaires and trust scales. The presentation of the findings is organised in the following sections: first, findings about the role of interpersonal trust between patients and providers; then the role of interpersonal trust at work places between co-workers and managers; and finally the role of institutional trust.
1050 L.R. Østergaard Table 1. Studies reviewed. Author/s (year)
Location
Dynes Ethiopia et al. (2013)
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Scott South et al. (2012) Africa
Olsen (2010)
Tanzania
van der Uganda, Kwaak Kenya et al. (2010) and Zambia
Arborio (2008)
Mali
Tibandebage and Mackintosh (2005)
Tanzania
Gilson South et al. (2005) Africa
Schneider (2005)
Rwanda
Objective To analyse trust among potentially competing coworkers and to develop a tool to measure trust in low-resource settings To explore the views of mid-level managers and nurses regarding the implementation of an equity-oriented staff allocation policy To analyse whether popular demand is neglected in the implementation of international policy frameworks under resource scarcity To develop a framework for analysing the encounters between providers and patients
To explore local concepts of maternity health risks through the way trust is practiced in different social relations To analyse how trust between providers and patients is constituted in health care market transactions To explore how patient– provider and provider– employer trust is related to primary health care responsiveness
To examine the role trust plays for consumers of micro-health insurance
Methodology
Forms of trust
Individual interviews and testing of a new scale to measure trust
Intergroup trust among health workers
In-depth interviews and focus-group discussion with nurses from primary care clinics and mid-level managers and document analysis Case study of emergency obstetric care
Intergroup trust between health workers
In-depth interviews with counsellors, patients and key informants, exit interviews, focus-group discussions, observations and a crosssectional survey In-depth interviews with policy-makers, health workers and the population
Interpersonal trust between health workers and patients
In-depth interviews with cadres in public and private sectors, exit interviews
Interpersonal trust between health workers and clients
Focus groups discussions with female users of public and private facilities, staff interviews and selfadministered questionnaires Focus groups
Interpersonal and intergroup trust
Institutional trust
Interpersonal trust between health workers and patients
Interpersonal trust between providers and clients
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Table 1 (Continued) Author/s (year) Birungi (1998)
Location
Objective
Methodology
Uganda
To explore the changing trends in injection use and practices in relation to perceptions of risk
Observation, interviews with community members and analysis of narratives
Forms of trust Institutional and technologybased trust
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Interpersonal trust between patients and providers The actor-oriented studies are particularly concerned with the way that people perceive how discretionary power is exercised by the providers. In a South African comparative study of private and public health facilities, Gilson, Palmer, and Schneider (2005) look at whether people have faith in the providers. The study presents data collected from statesponsored facilities which serve poor patients and private facilities serving a more affluent clientele. Clients at private facilities are much more likely to describe the providers as empathetic and respectful than patients at public facilities. Also, the providers employed at private facilities are more likely to find the quality of care they deliver to be satisfactory, and the community to express gratitude, than those who work at public facilities. This study reveals that trust is catalysed through more than verbal communication: clients are observant of providers’ facial expressions and intonations of words. If the clients find the providers to be respectful and fair during the interaction, they seem to be more likely to have faith in their professional competences. In this case clients have come to take it for granted that the routines practiced by providers are trustworthy, and both sides express positive expectations to each other. In contrast, patients at the public facilities more often describe the providers as impersonal and rude; the patients are critical of perceived provider neglect of confidentiality. Patients do not necessarily view the public providers as less competent, but they interpret their rudeness as lack of concern for the patient’s interests. One example is fears that what patients perceive as lack of empathy will translate into poor clinical quality of care. Staff at state-sponsored services are more likely to dislike their work, find that people abuse the services and distrust the community than those working at private facilities. As both sides of the trustor–trustee dyad are given a voice, it becomes possible for the authors to portray trust as a multi-directional phenomenon. Trust goes from patients to providers and from providers to patients, so that at some point in the course of interaction a trustee becomes the trustor. In a situation in which there seems to be convergence of reciprocal confidence, a more profound trust base emerges. The elements which are reported to provide a valid reason to trust the health workers are fair and empathetic exercise of discretionary power and perceived quality of care. Two papers examine trust as a question of whether patients have reasons to trust providers. In a study of a resource-constrained locality in Tanzania where providers practice bio-medicine in a context of material and technological limitations, patients are concerned about obtaining quality care at an affordable price (Tibandebage & Mackintosh, 2005). In a health system with minimal supervision and local accountability, there are few incentives for the providers to make any effort to include the poorest patients. Yet, some providers actually do and people interpret fair pricing as a sign of ethical standards: providers who are known not always to charge a fee to poor patients are
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1052 L.R. Østergaard perceived to use their discretionary power with fairness. Patients employ three tactics in their search for quality of care: they go to facilities known for fair pricing; to facilities where they already know a staff member; and they pay more in the hope it will yield better quality. In this study people report to trust health workers from the faith-based hospitals and the state-sponsored dispensaries rather than those at the private for-profit facilities, because providers who have chosen to work in the non-profit sector are believed to be motivated by a wish to serve the population. In a study from Rwanda about the weight people ascribe to trust when they decide whether to enrol in micro-health insurance schemes, Schneider (2005) analyses the nexus between expectations, trust and risk. People are so unsatisfied with the providers’ lack of responsiveness that they doubt whether the providers will protect the interests of the patients. In this case, people’s experiences with the services offered at the health facilities give them little reason to hope for quality treatment there. In spite of low levels of trust, Schneider does not find a correlation between trust and enrolment rates: people without alternative enrol out of dependency. Two papers look at trust as a matter of reflexivity, showing how trust is a social relation that works and is worked between the trustor and the trustee. In a study from rural Mali about maternal health risk perceptions, Arborio (2008) suggests that the limited demand for modern health services is linked to the public dispensaries’ dissonance with local sociocultural values. At the maternity ward the birthing women often experience rough treatment by the midwives, including being slapped, left alone for extended periods of time and accusations of practicing traditional medicines behind the back of the health personnel. Personal trust in the midwife compared to the traditional birth attendant influences where women will give birth. Pregnancy is associated with being at both physical and social risk, yet at the dispensary the focus is on biomedical efficacy alone. The physical risks are described as controllable by health professionals, whereas risks stemming from the social sphere, including those of witchcraft and jealousy, are omnipresent and internalised but not recognised in the modern health sector. The article concludes that trust issues are of relevance for fostering demand in health services. Asymmetric power relations in the health sector can be observed everywhere, but they are manifest in rural areas, where the distance in terms of cultural and economic capital between health professionals and villagers is considerable. The importance of ethnic congruence, language barriers, age, gender and cultural values for therapeutic collaboration seems to be important in relation to HIV/AIDS counselling because of the widespread enacted and perceived stigmatisation of HIV positive people inside and outside of the health system, which create barriers for uptake of HIV services as patients fear being met by negative attitudes from the health workers. If the providers demonstrate cultural resonance and empathy, the patients are more likely to dissolve sensitive details about their history and to engage in therapeutic collaboration (van der Kwaak, Ferris, van Kats, & Dieleman, 2010). These articles discuss trust as a reciprocal social phenomena between the providers and the community. Factors which appear to influence whether people come to trust the providers are perceived caring and empathetic attitude and whether providers exercise their discretionary power in a way that seems fair and predictable. Intergroup trust between co-workers and managers The centrality of workplace trust for health services is illustrated in a paper by Dynes, Hadley, Stephenson, and Sibley (2013) in which different cadres of health workers in
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rural Ethiopia concur that the ability to trust co-workers is important for work performances. By exploring health workers’ perspectives, the authors identify values which constitute the basis of trust in this context: formal education, transparent communication and personal characteristics, in particular ‘having oneness’. ‘Oneness’ relates to a personality which is perceived as consistently in harmony with socially accepted cultural values. Although trust is reported to be highest within the same group, there is a distinct cultural model of trust that all groups seem to agree on. Health professionals state that workplace trust gives patients a reason to demand services offered at the dispensaries because better collaboration among the providers will create the conditions for better communication among co-workers, leading to better clinical quality of care. Scott, Mathews, and Gilson (2012) discuss workplace trust based on a case of how nurses and mid-level managers negotiated the implementation of a new staff allocation policy in South Africa. The authors show how the management’s authority was eroded by the nurses’ dissatisfaction with the lack of autonomy in their daily work and the managers’ disrespect. Despite the nurses’ initial support of the policy, the legitimacy of the mid-level managers was undermined to such an extent that it hindered the implementation of the policy. By using a trust lens to go beyond the scope of a stakeholder analysis, the authors argue that resistance to new policy frameworks is not necessarily affected by whether the different actors anticipate losing or gaining from the changes. The study suggests that health worker motivation is not only fuelled by economic motives but also by trust in the management. While the relationship between providers and patients is of prime interest in most of the studies, the articles on intergroup relations suggest that trust is required between all actors in the health care sector. Trust between co-workers and between providers and managers contributes to popular trust in the health sector by increasing health worker job satisfaction, thereby motivating them to engage positively in their daily work.
Trust in institutions and in medical technologies Two articles discuss the critical role of institutions and medical technologies as trust builders or breakers. Birungi (1998) argues that demand for health services in the public sector decreased during the economic crisis in the 1980s in Uganda, where people lost faith in the safety of medical injections at public facilities, as they had been exposed to the dangers of unclean syringes and needles through HIV campaigns. Public health is based on the use of bio-medicine, which is an expensive and technology-intensive enterprise. When bio-medicine is practiced in a context of material deprivation and technological impoverishment, it has a negative effect on how people perceive the safety and quality of care (Wendland, 2010). In the case from Uganda, the tactics that the patients employed in their quest for medical quality were to personalise relationships with trustworthy providers, to bring their own syringes or to use the private injection facilities which proliferated during the crisis. People made their decisions based on individual risk assessments, taking into account the reputation of the facility and in particular the efficacy of the technologies offered there. Similarly, in the study from Tanzania (Gilson et al., 2005) one of the reasons why people failed to trust the public facilities was the fact that these facilities sold generic pharmaceutical drugs, believed to be of poor quality, compared to the branded drugs which could be obtained at the private clinics. According to Birungi (1998), a failing public health system in Uganda has not only undermined
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1054 L.R. Østergaard patients’ demand for state-sponsored services but also weakened popular trust in the public sector. The public health system in Africa has been subject to numerous reform initiatives and donor-driven changes often without due consideration to the needs of the local communities (Prince & Marsland, 2014). In a macro-level study from Tanzania about the effects of changing global health policy frameworks for health service demand, Olsen (2010) argues that policy makers have neglected popular trust. In this study of the provision of emergency obstetric care, it was found that new primary health facilities were established without being allocated the required number of qualified staff and adequate equipment. The consequence was that demand at this level of the health pyramid decreased. Olsen shows that, at a time when the public health system was under pressure, the primary health facilities had to do the work of other social sectors – particularly HIV education and prevention – to the detriment of curative services which the population urgently needed. These studies indicate that in addition to their contact with the providers, patients form knowledge about the quality of services, including those related to the available technologies, based on the reputation of a given health facility and the level and extent of risk that they might be exposed to there. As public health is based on the idea that health is a public good for which the state has a special responsibility towards its citizens, failure in securing a minimum level of medical safety appears to foster mistrust in the public sector. Discussion: towards a contextualised study of trust This review has explored the ways in which trust has been analysed as a matter of personal, institutional or technology-based trust in African health sector relationships in a small but robust body of literature. All the studies reviewed offer cases with rich descriptions of the views of different health sector actors. The studies adopted a process perspective in which health sector actors’ interpretations were central. Trust is never just one thing: the studies show trust as a multi-faceted concept embedded in the local context. It is striking that the studies set off to look for situations in which trust can grow but come back with examples of trust failures. However, if we accept that anxiety and not mistrust is the opposite of trust, as Geschiere (2013) argues, even the examples of failed trust offer important lessons about how to create better conditions for trust in health care. Read together, the studies provide four themes which seem to foster trust: sensitive use of discretionary power, perceived empathy, quality of medical care and workplace collegiality. These themes do not appear with the same weight in all studies but they appear across the three sets of health sector relationships which were introduced in the beginning. The power aspect is important in the public discussion about health care because the inherent asymmetry in knowledge, control and resources between professionals and laypeople puts the patient in a structurally vulnerable position compared to the provider. This must be acknowledged by health workers by their sensitive and fair exercise of discretionary power to create optimal conditions for therapeutic collaboration (Gilson et al., 2005; Tibandebage & Mackintosh, 2005). In the absence of enforced rules and effective supervision, the power gap creates fertile ground for manoeuvring, where discretion must be exercised when providers are confronted with demands for care that exceed the available resources. It also creates the need for health professionals to protect themselves against the frustrations arising from the suffering they are confronted with on a daily basis by creating a discursive distance between themselves and the patients
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(Kleinman, 2010). This is the case in the study from South Africa where public health workers in a poor community find that patients ‘abuse’ the health services (Gilson et al., 2005). Health providers are in a position to act as the gatekeepers, healers and helpers – or the contrary – of patients (Arborio, 2008; Ouattara, 2002; Schneider et al., 2010). In the articles where the providers actually used their power to provide care to poor patients, it has a positive impact on people’s sense of connectedness to that facility; in the contrary case, it induces a sense of inferiority as exemplified in this quote: ‘Failures of trust in the health care system, and broader social marginalisation, interact to “put people in their place”. To take a sick child home without attention is truly to know just how poor you are’ (Tibandebage & Mackintosh, 2005, p. 1394). In some contexts where there is a real choice between public and private facilities, people value the perceived quality of care offered by private and public providers differently, whereas this is not a topic in other contexts such as rural Mali where modern health services can only be found at state-sponsored dispensaries. In urban South Africa and Uganda, people value the availability of branded drugs, the medical security and health worker practice and conduct at the private clinics and ascribe higher levels of quality to these. However, in the study from Tanzania people reportedly have less trust in health workers who work for private for-profit institutions and have more trust in health workers in the non-profit sector, be it public or the faith-based facilities. Demonstrated empathy is important in several of the studies. Patients must be convinced that the providers actually care about their afflictions (Arborio, 2008; Gilson et al., 2005; Schneider, 2005). If the providers demonstrate empathy, cultural sensitivity and an understanding of social concerns, the communication will be more open and the patients will process information better (Thiede, 2005). These studies suggest that the public discussion about how to create demand for health services could benefit from including issues of perceived and enacted health worker empathy. The level of perceived fairness, respect and loyalty at the workplace between coworkers and between staff and managers appears to be crucial for the front line health workers’ motivation and job satisfaction (Dynes et al., 2013; Gilson et al., 2005; Scott et al., 2012). For the providers, it is a challenge to practice modern health care in a system in which the rules are poorly enforced, ethical behaviour is seldom rewarded by the management and where even the simplest diagnostic equipment are often lacking. These working conditions force the providers to improvise, to practice a different set of norms at work as compared to those which have been taught at medical school and challenge their professional identity (Martin, 2009; Wendland, 2010). Whereas most of the studies have focused on how people develop trust in the health systems through their interaction with the health workers, two studies have shown that in a situation where the formal organisation of the delivery of health services in government facilities is so inadequate and the safety of medical technology so insufficient that people do not only creatively develop other patterns of health seeking behaviours but also begin to distrust the public health sector (Birungi, 1998; Olsen, 2010). In health systems that for many reasons often fail to deliver better health, people cannot take quality of care for granted (Biehl & Petryna, 2013; Prince & Marsland, 2014). Yet, people make the leap of faith necessary to enter a health facility every day. The positive examples of trust show that trust functions as a means to reduce the complexity grafted upon health care, whereas the examples of mistrust illustrate how lack of trust adds to that complexity and leaves patients in a state of dependency. Interpreted together, the studies suggest that discretionary power exercised with fairness, perceived empathy, medical quality and workplace collegiality can facilitate trust
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in health sector relations. Trust is not only dependent on the providers’ medical expertise and communication skills, or on the reputation of the facility. Rather, it is connected to situations where people have reason to trust in the provider, the institution and the medico-technical equipment; where trust has become a routine over time and not a singular event; and where those in power actively reflect on how they can interact with those without power in the best possible way.
Conclusion: trust matters to global health The study of trust as practiced in health sector relationships has the potential to offer insights about ways to improve collaboration in the health sector. As the global health community moves forward in discussions of the post-2015 agenda, there is an increasing concern for improving health systems, knowing that the health care needs of a growing world population will put existing services under pressure (Duflo, 2010). This narrative review indicates that further exploration is needed to fully understand the relationship between trust and demand for health services. Many questions remain unanswered, but one stands out: how can we support health care actors – providers, patients and managers – in building positive expectations of each other, creating fertile ground for trusting relationships? The trust dividend from a better engagement between health providers and patients can potentially improve the demand for health services. This engagement could be strengthened through clearer accountability mechanisms for local health committees, better training of health workers’ relational and communication competencies and a focus by supervisors on how to create collegiality between providers and mid-level managers. Since trust is not a given, it will be repeatedly tested and must constantly be reaffirmed at all levels of the health care pyramid. If it is not, failed trust relationships may contribute to a breach between the people and the public system that is supposed to provide basic social services. In a situation in which the need to optimise the functioning of health service delivery is urgent, building trustworthy health systems is one way to move ahead. Acknowledgements I would like to thank Helle Samuelsen, Department of Anthropology, University of Copenhagen (UoC), Siri Tellier, Department of International Health, Immunology and Microbiology (ISIM), UoC, Tania Dræbel, ISIM, UoC, Britt Tersbøl, ISIM, UoC and Ole Nørgaard, UoC for their valuable observations during the preparation of the manuscript. I also wish to acknowledge the constructive comments by the three anonymous reviewers.
Disclosure statement No potential conflict of interest was reported by the author.
Funding This research was supported by Danida Fellowship Centre under the Danish Ministry of Foreign Affairs [grant number 11-014KU] as a part of the research project ‘Fragile Futures: Rural Lives in times of Conflict’.
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Note 1. As a part of the research project ‘Fragile Futures: Rural Lives in times of Conflict’, I conducted ethnographic fieldwork in Burkina Faso exploring how villagers utilise the public health system in remote areas.
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References Andersen, H. M. (2004). Villagers: Differential treatment in a Ghanaian hospital. Social Science & Medicine, 59, 2003–2012. doi:10.1016/j.socscimed.2004.03.005 Arborio, S. (2008). Maternité sans risque: du contrôle à la confiance. Analyse anthropologique du risque su Mali (Afrique de l’Ouest) [Safe motherhood initiative: From control to trust: Anthropological analysis of risk in Mali (West Africa)]. Journal de Gynéocologie Obstétrique et Biologie de la Reproduction, 37, 48–56. Baltussen, R. M. P. M., Yé, Y., Haddad, S., & Sauerborn, R. S. (2002). Perceived quality of primary health care services in Burkina Faso. Health Policy and Planning, 17(1), 42–48. doi:10.1093/ heapol/17.1.42 Baumeister, R. F., & Leary, M. R. (1997). Writing narrative literature reviews. Review of General Psychology, 1, 311–320. doi:10.1037/1089-2680.1.3.311 Biehl, J. G., & Petryna, A. (2013). When people come first: Critical studies in global health. Princeton: Princeton University Press. Birungi, H. (1998). Injections and self-help: Risk and trust in Ugandan health care. Social Science & Medicine, 47, 1455–1462. doi:10.1016/S0277-9536(98)00194-4 Britten, N., Campbell, R., Pope, C., Donovan, J., Morgan, M., & Pill, R. (2002). Using meta ethnography to synthesise qualitative research: A worked example. Journal of Health Services Research & Policy, 7, 209–215. doi:10.1258/135581902320432732 Calnan, M., Rowe, R., & Entwistle, V. (2006). Trust relations in health care: An agenda for future research. Journal of Health Organization and Management, 20, 477–484. doi:10.1108/ 14777260610701830 Duflo, E. (2010). Le Développment Humain (Lutter contre la pauvrete, volume 1), [Human development (Fighting poverty, volume 1)] La république des idées. Paris: Seuil. Dynes, M. M., Hadley, C., Stephenson, R., & Sibley, L. M. (2013). Measuring trust among frontline health workers in rural Ethiopia. Human Organization, 72, 230–241. Geissler, P. W. (2014). The archipelago of public health: Comment on the landscape of medical research in twenty-first-century Africa. In R. J. Prince & R. Marsland (Eds.), Making and unmaking public health in Africa: Ethnographic and historical perspectives. Athens: Ohio University Press. Geschiere, P. (2013). Witchcraft, intimacy, and trust: Africa in comparison. Chicago: University of Chicago Press. Giddens, A. (1990). The consequences of modernity. Cambridge: Polity Press. Gilson, L. (2003). Trust and the development of health care as a social institution. Social Science & Medicine, 56, 1453–1468. doi:10.1016/S0277-9536(02)00142-9 Gilson, L. (2005). Editorial: Building trust and value in health systems in low- and middle-income countries. Social Science & Medicine, 61, 1381–1384. doi:10.1016/j.socscimed.2004.11.059 Gilson, L. (2006). Trust in health care: Theoretical perspectives and research needs. Journal of Health Organization and Management, 20, 359–375. doi:10.1108/14777260610701768 Gilson, L., Palmer, N., & Schneider, H. (2005). Trust and health worker performance: Exploring a conceptual framework using South African evidence. Social Science & Medicine, 61, 1418– 1429. doi:10.1016/j.socscimed.2004.11.062 Goudge, J., & Gilson, L. (2005). How can trust be investigated? Drawing lessons from past experience. Social Science & Medicine, 61, 1439–1451. doi:10.1016/j.socscimed.2004.11.071 Green, B. N., Johnson, C. D., & Adams, A. (2006). Writing narrative literature reviews for peerreviewed journals: Secrets of the trade. Journal of Chiropractic Medicine, 5(3), 101–117. doi:10.1016/S0899-3467(07)60142-6 Grimen, H. (2009). Power, trust, and risk: Some reflections on an absent issue. Medical Anthropology Quarterly, 23(1), 16–33. doi:10.1111/j.1548-1387.2009.01035.x Kleinman, A. (2010). Caregiving: The divided meaning of being human and the divided self of the caregiver. In M. J. Molina & D. K. Swearer (Eds.), Rethinking the human (pp. 17–31). Cambridge, MA: Center for the Study of World Religions and Harvard University Press.
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1058 L.R. Østergaard Martin, H. M. (2009). Nursing contradictions: Ideals and improvisation in Uganda, Health, culture, and society. Diemen: AMB Press. Masquelier, A. (2001). Behind the dispensary’s prosperous facade: Imagining the state in rural Niger. Public Culture, 13, 267–292. doi:10.1215/08992363-13-2-267 Mechanic, D., & Meyer, S. (2000). Concepts of trust among patients with serious illness. Social Science & Medicine, 51, 657–668. doi:10.1016/S0277-9536(00)00014-9 Misztal, B. A. (1996). Trust in modern societies: The search for the bases of social order. Cambridge: Polity Press. Möllering, G. (2006). Trust: Reason, routine, reflexivity. Oxford: Elsevier. Molyneux, C. S., Peshu, N., & Marsh, K. (2005). Trust and informed consent: Insights from community members on the Kenyan coast. Social Science & Medicine, 61, 1463–1473. doi:10.1016/j.socscimed.2004.11.073 Olsen, O. E. (2010). The impact of global health initiatives on trust in health care provision under extreme resource scarcity: Presenting an agenda for debate from a case study of emergency obstetric care in Northern Tanzania. Health Research Policy and Systems, 8, 14. Ouattara, F. 2002. Gouvernances quotidiennes au coeur des structures de sante les cas d’Orodara et de Banfora, Burkina Faso [Everyday governance in health facilities. The case of Orodara and Banfora, Burkina Faso]. Bulletin de l’APAD, 23–24, 1–15. Retrieved from http://apad.revues. org/145 Ozawa, S., & Walker, D. G. (2011). Comparison of trust in public vs private health care providers in rural Cambodia. Health Policy and Planning, 26(Suppl. 1), i20–i29. doi:10.1093/heapol/ czr045 Prince, R. J., & Marsland, R. (Eds.). (2014). Making and unmaking public health in Africa: Ethnographic and historical perspectives. Athens, OH: Ohio University Press. Ridde, V. (2008). The problem of the worst-off is dealt with after all other issues: The equity and health policy implementation gap in Burkina Faso. Social Science & Medicine, 66, 1368–1378. doi:10.1016/j.socscimed.2007.10.026 Rowe, R., & Calnan, M. (2006). Trust relations in health care – The new agenda. European Journal of Public Health, 16(1), 4–6. doi:10.1093/eurpub/ckl004 Samuelsen, H. (2004). Therapeutic itineraries: The medical field in rural Burkina Faso. Anthropology & Medicine, 11(1), 27–41. doi:10.1080/1364847042000204933 Samuelsen, H., Norgaard, O., & Østergaard, L. R. (2012). Social and cultural aspects of HIV and AIDS in West Africa: A narrative review of qualitative research. SAHARA J: Journal of Social Aspects of AIDS, 9(2), 64–73. doi:10.1080/17290376.2012.683580 Schneider, P. (2005). Trust in micro-health insurance: An exploratory study in Rwanda. Social Science & Medicine, 61, 1430–1438. doi:10.1016/j.socscimed.2004.11.074 Schneider, H., le Marcis, F., Grard, J., Penn-Kekana, L., Blaauw, D., & Fassin, D. (2010). Negotiating care: Patient tactics at an urban South African hospital. Journal of Health Services Research and Policy, 15(3), 137–142. doi:10.1258/jhsrp.2010.008174 Scott, V., Mathews, V., & Gilson, L. (2012). Constraints to implementing an equity-promoting staff allocation policy: Understanding mid-level managers’ and nurses’ perspectives affecting implementation in South Africa. Health Policy & Planning, 27(2), 138–146. doi:10.1093/ heapol/czr020 Thiede, M. (2005). Information and access to health care: Is there a role for trust? Social Science & Medicine, 61, 1452–1462. doi:10.1016/j.socscimed.2004.11.076 Tibandebage, P., & Mackintosh, M. (2005). The market shaping of charges, trust and abuse: Health care transactions in Tanzania. Social Science & Medicine, 61, 1385–1395. doi:10.1016/j. socscimed.2004.11.072 van der Kwaak, A., Ferris, K., van Kats, J., & Dieleman, M. (2010). Performances of sexuality counselling: A framework for provider–client encounters. Patient Education and Counseling, 81, 338–342. doi:10.1016/j.pec.2010.10.012 Walt, G. (1994). Health policy: An introduction of process and power. London: Zed Books. Wendland, C. L. (2010). A heart for the work: Journeys through an African medical school. Chicago and London: The University of Chicago Press. Whyte, S. R. (2002). Subjectivity and subjunctivity: Hoping for health in eastern Uganda. In R. P. Werbner (Ed.), Postcolonial subjectivities in Africa (pp. 171–190). London and New York: Zed Books.
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ISSN: 1744-1692 (Print) 1744-1706 (Online) Journal homepage: http://www.tandfonline.com/loi/rgph20
Trust matters: A narrative literature review of the role of trust in health care systems in sub-Saharan Africa Lise Rosendal Østergaard To cite this article: Lise Rosendal Østergaard (2015) Trust matters: A narrative literature review of the role of trust in health care systems in sub-Saharan Africa, Global Public Health, 10:9, 1046-1059, DOI: 10.1080/17441692.2015.1019538 To link to this article: http://dx.doi.org/10.1080/17441692.2015.1019538
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Date: 06 November 2015, At: 02:40
Global Public Health, 2015 Vol. 10, No. 9, 1046–1059, http://dx.doi.org/10.1080/17441692.2015.1019538
Trust matters: A narrative literature review of the role of trust in health care systems in sub-Saharan Africa Lise Rosendal Østergaard*
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Department of Anthropology, Faculty of Social Sciences, University of Copenhagen, Copenhagen, Denmark (Received 20 February 2014; accepted 10 January 2015) This article makes a contribution to the debate about health service utilisation and the role of trust in fostering demand for health services in sub-Saharan Africa. It is framed as a narrative literature review based on a thematic analysis of nine empirical, qualitative studies. For the purposes of this article trust is defined as a voluntary course of action, which involves the optimistic expectation that the trustee will do no harm to the trustor and is increasingly perceived as an important influence on health system functioning. The article looks at trust issues in interpersonal, intergroup and institutional situations. The findings of the review point to four elements that are important for trust to develop in health sector relationships: the sensitive use of discretionary power by health workers, perceived empathy by patients of the health workers, the quality of medical care and workplace collegiality. When trust works in health sector encounters, it reduces the social complexity and inherent uneven distribution of power between clients and providers. The article concludes that understanding and supporting trust processes between patients and providers, as well as between co-workers and managers, will improve health sector collaboration and stimulate demand for health care services. Keywords: situations of trust; mistrust; ethnographic methods; narrative literature review; sub-Saharan Africa
Introduction ‘I give myself to you’. That is how trust is commonly translated in Moré, one of the languages spoken in Burkina Faso. During ethnographic fieldwork for a research project on how people in rural areas navigate the different health service options, the precariousness of trust in the public health care system kept coming up as a basic but far from trivial concern.1 It was the importance that health workers and patients ascribed to trust, which inspired this article. I argue that trust is an important factor in health care encounters and that a critical review of existing qualitative research can be a fruitful step in understanding the role trust plays in different types of health sector interactions. The article, therefore, reviews what the qualitative literature on trust in sub-Saharan Africa has to offer to the debate on health service demand. As people’s views are given more prominence in policy-making (Baltussen, Yé, Haddad, & Sauerborn, 2002), there is a growing interest in understanding which qualities patients find important and thus determine whether they develop trust in health care *Email: [email protected] © 2015 Taylor & Francis
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(Gilson, 2003, 2005; Ozawa & Walker, 2011; Thiede, 2005). A better understanding of not only actual but also perceived quality could contribute to improving demand for modern health services in low-income countries (Calnan, Rowe, & Entwistle, 2006; Gilson, 2005). In modern health care systems, the foundation for trust is that the patients in principle can have confidence in the health professionals’ expertise, conduct and practice because the sector is sanctioned by the state. In practice, lay people form knowledge about the health system through interaction with the front line health workers and experience with the material conditions and equipment of the health facility (Whyte, 2014). It is through these encounters that perceptions about quality are formed. There are two dominant theoretical answers to why trust matters to health care systems (Gilson, 2006). First, trust has the potential to improve therapeutic collaboration between provider and patient which is a precondition for the production of health (Gilson, 2003; Mechanic & Meyer, 2000). It is easier for the patient to disclose symptoms and to comply with treatment instructions if she or he has faith in the provider’s sense of confidentiality, competences and respect. The centrality of trust for therapeutic collaboration stems from the structurally uneven distribution of power between health professionals and patients. The provider has medical knowledge, clinical expertise and control over prescriptions and referrals, whereas the patient is in need of care (Grimen, 2009; Rowe & Calnan, 2006). Second, trust contributes to wider social value and civic engagement. The health sector not only produces health but also imaginaries of stateprovided social protection, because it is the state that has responsibility for regulating the sector (Duflo, 2010; Walt, 1994). This argument reflects broader concerns about the relationship between health care and citizenship, and is based on the assumption that if people receive quality care in the public services they seem to express greater trust in the state (Gilson, 2003). Thus a health system which is perceived as trustworthy has the potential to create a bond between the citizens and the state. This has implications for matters of equity as poor people in poor countries tend to express lower levels of trust in the public health sector (Gilson, 2006, p. 364). Ethnographic studies have shown how vulnerable and poor population groups are more likely to be subject to differential care by health providers in the public instutions and have fewer positive expectations of the health services (Andersen, 2004; Masquelier, 2001; Ridde, 2008). The failure of the public health sector to create the conditions for trusting relationships can thus further contribute to the marginalisation in society of vulnerable population groups. From the social science literature, trust appears not only as a powerful analytical concept but also as an evasive notion; fundamental questions remain on how trust can be defined, as well as how different actors view its core elements (Möllering, 2006). Goudge and Gilson (2005) define trust across cultural contexts as ‘a judgment in a situation of risk that the trustee will act in the best interests of the trustor, or at least in ways that will not be harmful to the trustor’ (p. 1440). In this sense trust is a voluntary course of action which is taken in a situation without full information, based on the optimistic expectation that the trustee will do no harm to the trustor (Giddens, 1990). Möllering (2006) argues that trust requires a ‘leap of faith’ where the trustor gives himself to the trustee in order to suspend the doubt that the trustor may have about the trustee’s intentions. Trust differs from adherence because it is based on an active choice made within the ambiguity of existing social relations. It is forward-looking, installing positive expectations, and thus differs from patient satisfaction which is based on past experience. According to Luhman (1979), the function of trust is to ‘reduce social complexity by going beyond available information and generalising expectations of behavior in that it replaces missing information with an internally guaranteed security’ (p. 93, cited in Misztal, 1996).
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1048 L.R. Østergaard A health care encounter can be a complex social situation. Here trust operates as a way of solving the problem of the power gap without eliminating it. The gap persists, but it becomes possible for the patient to act as if it were not there and to suspend the irreductible uncertainty of a medical encounter (Möllering, 2006, p. 6). In line with the previously mentioned observations from Burkina Faso, Geschiere (2013) argues that trust must be understood as a phenomenon which is ‘precarious and situational (never “ontological”)’ (p. xiii). The research field on the role of trust in the health sector is dominated by studies based on quantitative methods scrutinising the extent and distribution of trust as a predefined phenomenon across a population. In spite of the valuable contributions of this approach, it is not well suited to provide insights into how people make meaning of trust. The aim of qualitative research is to produce an understanding of people’s life worlds, what they hope for and how they deal with their vital problems such as obtaining quality health care (Whyte, 2002, p. 172). In her influential article on health care as a social institution, Gilson (2003) suggests that the health sector must be understood as ‘inherently relational’ (p. 1453), leading her to the conclusion that some of the challenges which the sector is exposed to are relational. Seen from this perspective, the quality of health sector relations becomes critical for the sector’s ability to produce health and civic engagement. Following that line of thought, the present review is based on qualitative studies using ethnographic methods such as in-depth interviews and focus groups in order to capture the local specificities which frame these relationships. The reviewed studies examine how trust is perceived and lived by health sector actors in three sets of relations: between patients and providers, between co-workers and finally as the trust that people can have in health institutions or in medical technologies. This framework has been identified through a content analysis of the selected studies. First, we will look at interpersonal relationships where trust grows out of personalised interactions, either between patient and provider or between people who work together. Second, we will look at examples of how people can develop a trusting relationship with an institution based on perceived quality, safety and cultural appropriateness of services provided, e.g., a private clinic compared to a public facility. Medical anthropologists have shown how people in societies with faltering public health services tend to place their hope for cure and care in private facilities, where they expect to be treated like a client rather than a simple patient (Samuelsen, 2004; Whyte, 2005). Third, examples of how trust can be based in an institution or a medical technology is discussed. This kind of trust is based on the patient’s faith in the efficacy of the technology itself rather than the provider administering it or the institution offering it, e.g., in the power of injections (Whyte, van der Geest, & Hardon, 2002). In the conclusion, we will see that four aspects appear to build or break trust in health sector encounters: sensitive use of discretionary power, perceived empathy, quality of medical care and workplace collegiality.
Methodology This article is framed as a narrative literature review. This method rather than a systematic literature review has been chosen because narrative reviews allow for the analytical integration of studies that differ in terms of methodology but which capture different perspectives of a social phenomenon (Samuelsen, Norgaard, & Østergaard, 2012). These studies would have been difficult to bring together within the rigorous design of systematic reviews (Green, Johnson, & Adams, 2006).
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The article draws on studies identified by the author assisted by a research librarian. We conducted a comprehensive search in six computerised databases: Web of Science, SCOPUS, Medline, FRANCIS, Anthropology Plus and Google Scholar. Different terms related to trust, health care, health workers and Africa were used. No period was specified, and articles published in English and French were included. In order to ensure a level of academic quality, the review comprises only peer-reviewed articles. An important subset of literature studies the role of trust in medical research trials (Geissler, 2014; Molyneux, Peshu, & Marsh, 2005), but these types of trust relations seem to have higher levels of uncertainty and different ethical stakes compared to patient–provider engagement, so they have not been included. Following these criteria, nine studies were selected. Table 1 provides the details of each study. There are at least two sets of limitations to the search strategy. First, it cannot be excluded that ethnographic studies are less rigorously indexed in databases than for example public health studies, thus some articles might be missing if they have been wrongly indexed. The chances have been minimised through a manual retrieval of the abstracts to scrutinise the literature lists for studies that did not appear in the database searches. Second, in order to have a manageable volume of material, books are not a part of this review, which is a weakness because some ethnographic studies are published in anthologies instead of as articles. A stepwise approach has been followed in the analytical work. After the selection of a body of literature, the first step was to identify the purpose and the perspective on trust of each study with the objective of seeing how the studies link together (Baumeister & Leary, 1997; Britten et al., 2002). Then the findings regarding the bases of trust of each paper were analysed using a thematic approach. Finally, the identified themes were sought and synthesised. As the context of the studies differs, a rigorous comparative analysis has not been attempted. Findings Empirically, eight of the reviewed articles are located in southern and eastern Africa, with the majority of the cases coming from urban or semi-urban localities, and two from exclusively rural settings. Analytically, the articles share a view on health care as a social institution in which trust must be analysed as a relational and context-specific phenomenon. Eight of the articles are actor-oriented, placing their interest in capturing the perspectives of different actors; one study is primarily system-oriented, looking at trust issues at the macro-level. All studies are explorative and designed to ask open-ended questions. Methodologically, they use detailed ethnographic accounts produced over an extensive period of time. Four of the studies were originally designed to study trust, but those which were not have drawn on large data-sets to conduct a focused analysis of trust aspects. Their retrospective interest in trust stems from the weight with which trust issues were raised by the informants. The studies use qualitative methodologies including observations, focusgroup discussions, in-depth interviews and document analysis. Some of the studies combine qualitative with quantitative methods, such as statistical analysis of selfadministered questionnaires and trust scales. The presentation of the findings is organised in the following sections: first, findings about the role of interpersonal trust between patients and providers; then the role of interpersonal trust at work places between co-workers and managers; and finally the role of institutional trust.
1050 L.R. Østergaard Table 1. Studies reviewed. Author/s (year)
Location
Dynes Ethiopia et al. (2013)
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Scott South et al. (2012) Africa
Olsen (2010)
Tanzania
van der Uganda, Kwaak Kenya et al. (2010) and Zambia
Arborio (2008)
Mali
Tibandebage and Mackintosh (2005)
Tanzania
Gilson South et al. (2005) Africa
Schneider (2005)
Rwanda
Objective To analyse trust among potentially competing coworkers and to develop a tool to measure trust in low-resource settings To explore the views of mid-level managers and nurses regarding the implementation of an equity-oriented staff allocation policy To analyse whether popular demand is neglected in the implementation of international policy frameworks under resource scarcity To develop a framework for analysing the encounters between providers and patients
To explore local concepts of maternity health risks through the way trust is practiced in different social relations To analyse how trust between providers and patients is constituted in health care market transactions To explore how patient– provider and provider– employer trust is related to primary health care responsiveness
To examine the role trust plays for consumers of micro-health insurance
Methodology
Forms of trust
Individual interviews and testing of a new scale to measure trust
Intergroup trust among health workers
In-depth interviews and focus-group discussion with nurses from primary care clinics and mid-level managers and document analysis Case study of emergency obstetric care
Intergroup trust between health workers
In-depth interviews with counsellors, patients and key informants, exit interviews, focus-group discussions, observations and a crosssectional survey In-depth interviews with policy-makers, health workers and the population
Interpersonal trust between health workers and patients
In-depth interviews with cadres in public and private sectors, exit interviews
Interpersonal trust between health workers and clients
Focus groups discussions with female users of public and private facilities, staff interviews and selfadministered questionnaires Focus groups
Interpersonal and intergroup trust
Institutional trust
Interpersonal trust between health workers and patients
Interpersonal trust between providers and clients
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Table 1 (Continued) Author/s (year) Birungi (1998)
Location
Objective
Methodology
Uganda
To explore the changing trends in injection use and practices in relation to perceptions of risk
Observation, interviews with community members and analysis of narratives
Forms of trust Institutional and technologybased trust
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Interpersonal trust between patients and providers The actor-oriented studies are particularly concerned with the way that people perceive how discretionary power is exercised by the providers. In a South African comparative study of private and public health facilities, Gilson, Palmer, and Schneider (2005) look at whether people have faith in the providers. The study presents data collected from statesponsored facilities which serve poor patients and private facilities serving a more affluent clientele. Clients at private facilities are much more likely to describe the providers as empathetic and respectful than patients at public facilities. Also, the providers employed at private facilities are more likely to find the quality of care they deliver to be satisfactory, and the community to express gratitude, than those who work at public facilities. This study reveals that trust is catalysed through more than verbal communication: clients are observant of providers’ facial expressions and intonations of words. If the clients find the providers to be respectful and fair during the interaction, they seem to be more likely to have faith in their professional competences. In this case clients have come to take it for granted that the routines practiced by providers are trustworthy, and both sides express positive expectations to each other. In contrast, patients at the public facilities more often describe the providers as impersonal and rude; the patients are critical of perceived provider neglect of confidentiality. Patients do not necessarily view the public providers as less competent, but they interpret their rudeness as lack of concern for the patient’s interests. One example is fears that what patients perceive as lack of empathy will translate into poor clinical quality of care. Staff at state-sponsored services are more likely to dislike their work, find that people abuse the services and distrust the community than those working at private facilities. As both sides of the trustor–trustee dyad are given a voice, it becomes possible for the authors to portray trust as a multi-directional phenomenon. Trust goes from patients to providers and from providers to patients, so that at some point in the course of interaction a trustee becomes the trustor. In a situation in which there seems to be convergence of reciprocal confidence, a more profound trust base emerges. The elements which are reported to provide a valid reason to trust the health workers are fair and empathetic exercise of discretionary power and perceived quality of care. Two papers examine trust as a question of whether patients have reasons to trust providers. In a study of a resource-constrained locality in Tanzania where providers practice bio-medicine in a context of material and technological limitations, patients are concerned about obtaining quality care at an affordable price (Tibandebage & Mackintosh, 2005). In a health system with minimal supervision and local accountability, there are few incentives for the providers to make any effort to include the poorest patients. Yet, some providers actually do and people interpret fair pricing as a sign of ethical standards: providers who are known not always to charge a fee to poor patients are
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1052 L.R. Østergaard perceived to use their discretionary power with fairness. Patients employ three tactics in their search for quality of care: they go to facilities known for fair pricing; to facilities where they already know a staff member; and they pay more in the hope it will yield better quality. In this study people report to trust health workers from the faith-based hospitals and the state-sponsored dispensaries rather than those at the private for-profit facilities, because providers who have chosen to work in the non-profit sector are believed to be motivated by a wish to serve the population. In a study from Rwanda about the weight people ascribe to trust when they decide whether to enrol in micro-health insurance schemes, Schneider (2005) analyses the nexus between expectations, trust and risk. People are so unsatisfied with the providers’ lack of responsiveness that they doubt whether the providers will protect the interests of the patients. In this case, people’s experiences with the services offered at the health facilities give them little reason to hope for quality treatment there. In spite of low levels of trust, Schneider does not find a correlation between trust and enrolment rates: people without alternative enrol out of dependency. Two papers look at trust as a matter of reflexivity, showing how trust is a social relation that works and is worked between the trustor and the trustee. In a study from rural Mali about maternal health risk perceptions, Arborio (2008) suggests that the limited demand for modern health services is linked to the public dispensaries’ dissonance with local sociocultural values. At the maternity ward the birthing women often experience rough treatment by the midwives, including being slapped, left alone for extended periods of time and accusations of practicing traditional medicines behind the back of the health personnel. Personal trust in the midwife compared to the traditional birth attendant influences where women will give birth. Pregnancy is associated with being at both physical and social risk, yet at the dispensary the focus is on biomedical efficacy alone. The physical risks are described as controllable by health professionals, whereas risks stemming from the social sphere, including those of witchcraft and jealousy, are omnipresent and internalised but not recognised in the modern health sector. The article concludes that trust issues are of relevance for fostering demand in health services. Asymmetric power relations in the health sector can be observed everywhere, but they are manifest in rural areas, where the distance in terms of cultural and economic capital between health professionals and villagers is considerable. The importance of ethnic congruence, language barriers, age, gender and cultural values for therapeutic collaboration seems to be important in relation to HIV/AIDS counselling because of the widespread enacted and perceived stigmatisation of HIV positive people inside and outside of the health system, which create barriers for uptake of HIV services as patients fear being met by negative attitudes from the health workers. If the providers demonstrate cultural resonance and empathy, the patients are more likely to dissolve sensitive details about their history and to engage in therapeutic collaboration (van der Kwaak, Ferris, van Kats, & Dieleman, 2010). These articles discuss trust as a reciprocal social phenomena between the providers and the community. Factors which appear to influence whether people come to trust the providers are perceived caring and empathetic attitude and whether providers exercise their discretionary power in a way that seems fair and predictable. Intergroup trust between co-workers and managers The centrality of workplace trust for health services is illustrated in a paper by Dynes, Hadley, Stephenson, and Sibley (2013) in which different cadres of health workers in
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rural Ethiopia concur that the ability to trust co-workers is important for work performances. By exploring health workers’ perspectives, the authors identify values which constitute the basis of trust in this context: formal education, transparent communication and personal characteristics, in particular ‘having oneness’. ‘Oneness’ relates to a personality which is perceived as consistently in harmony with socially accepted cultural values. Although trust is reported to be highest within the same group, there is a distinct cultural model of trust that all groups seem to agree on. Health professionals state that workplace trust gives patients a reason to demand services offered at the dispensaries because better collaboration among the providers will create the conditions for better communication among co-workers, leading to better clinical quality of care. Scott, Mathews, and Gilson (2012) discuss workplace trust based on a case of how nurses and mid-level managers negotiated the implementation of a new staff allocation policy in South Africa. The authors show how the management’s authority was eroded by the nurses’ dissatisfaction with the lack of autonomy in their daily work and the managers’ disrespect. Despite the nurses’ initial support of the policy, the legitimacy of the mid-level managers was undermined to such an extent that it hindered the implementation of the policy. By using a trust lens to go beyond the scope of a stakeholder analysis, the authors argue that resistance to new policy frameworks is not necessarily affected by whether the different actors anticipate losing or gaining from the changes. The study suggests that health worker motivation is not only fuelled by economic motives but also by trust in the management. While the relationship between providers and patients is of prime interest in most of the studies, the articles on intergroup relations suggest that trust is required between all actors in the health care sector. Trust between co-workers and between providers and managers contributes to popular trust in the health sector by increasing health worker job satisfaction, thereby motivating them to engage positively in their daily work.
Trust in institutions and in medical technologies Two articles discuss the critical role of institutions and medical technologies as trust builders or breakers. Birungi (1998) argues that demand for health services in the public sector decreased during the economic crisis in the 1980s in Uganda, where people lost faith in the safety of medical injections at public facilities, as they had been exposed to the dangers of unclean syringes and needles through HIV campaigns. Public health is based on the use of bio-medicine, which is an expensive and technology-intensive enterprise. When bio-medicine is practiced in a context of material deprivation and technological impoverishment, it has a negative effect on how people perceive the safety and quality of care (Wendland, 2010). In the case from Uganda, the tactics that the patients employed in their quest for medical quality were to personalise relationships with trustworthy providers, to bring their own syringes or to use the private injection facilities which proliferated during the crisis. People made their decisions based on individual risk assessments, taking into account the reputation of the facility and in particular the efficacy of the technologies offered there. Similarly, in the study from Tanzania (Gilson et al., 2005) one of the reasons why people failed to trust the public facilities was the fact that these facilities sold generic pharmaceutical drugs, believed to be of poor quality, compared to the branded drugs which could be obtained at the private clinics. According to Birungi (1998), a failing public health system in Uganda has not only undermined
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1054 L.R. Østergaard patients’ demand for state-sponsored services but also weakened popular trust in the public sector. The public health system in Africa has been subject to numerous reform initiatives and donor-driven changes often without due consideration to the needs of the local communities (Prince & Marsland, 2014). In a macro-level study from Tanzania about the effects of changing global health policy frameworks for health service demand, Olsen (2010) argues that policy makers have neglected popular trust. In this study of the provision of emergency obstetric care, it was found that new primary health facilities were established without being allocated the required number of qualified staff and adequate equipment. The consequence was that demand at this level of the health pyramid decreased. Olsen shows that, at a time when the public health system was under pressure, the primary health facilities had to do the work of other social sectors – particularly HIV education and prevention – to the detriment of curative services which the population urgently needed. These studies indicate that in addition to their contact with the providers, patients form knowledge about the quality of services, including those related to the available technologies, based on the reputation of a given health facility and the level and extent of risk that they might be exposed to there. As public health is based on the idea that health is a public good for which the state has a special responsibility towards its citizens, failure in securing a minimum level of medical safety appears to foster mistrust in the public sector. Discussion: towards a contextualised study of trust This review has explored the ways in which trust has been analysed as a matter of personal, institutional or technology-based trust in African health sector relationships in a small but robust body of literature. All the studies reviewed offer cases with rich descriptions of the views of different health sector actors. The studies adopted a process perspective in which health sector actors’ interpretations were central. Trust is never just one thing: the studies show trust as a multi-faceted concept embedded in the local context. It is striking that the studies set off to look for situations in which trust can grow but come back with examples of trust failures. However, if we accept that anxiety and not mistrust is the opposite of trust, as Geschiere (2013) argues, even the examples of failed trust offer important lessons about how to create better conditions for trust in health care. Read together, the studies provide four themes which seem to foster trust: sensitive use of discretionary power, perceived empathy, quality of medical care and workplace collegiality. These themes do not appear with the same weight in all studies but they appear across the three sets of health sector relationships which were introduced in the beginning. The power aspect is important in the public discussion about health care because the inherent asymmetry in knowledge, control and resources between professionals and laypeople puts the patient in a structurally vulnerable position compared to the provider. This must be acknowledged by health workers by their sensitive and fair exercise of discretionary power to create optimal conditions for therapeutic collaboration (Gilson et al., 2005; Tibandebage & Mackintosh, 2005). In the absence of enforced rules and effective supervision, the power gap creates fertile ground for manoeuvring, where discretion must be exercised when providers are confronted with demands for care that exceed the available resources. It also creates the need for health professionals to protect themselves against the frustrations arising from the suffering they are confronted with on a daily basis by creating a discursive distance between themselves and the patients
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(Kleinman, 2010). This is the case in the study from South Africa where public health workers in a poor community find that patients ‘abuse’ the health services (Gilson et al., 2005). Health providers are in a position to act as the gatekeepers, healers and helpers – or the contrary – of patients (Arborio, 2008; Ouattara, 2002; Schneider et al., 2010). In the articles where the providers actually used their power to provide care to poor patients, it has a positive impact on people’s sense of connectedness to that facility; in the contrary case, it induces a sense of inferiority as exemplified in this quote: ‘Failures of trust in the health care system, and broader social marginalisation, interact to “put people in their place”. To take a sick child home without attention is truly to know just how poor you are’ (Tibandebage & Mackintosh, 2005, p. 1394). In some contexts where there is a real choice between public and private facilities, people value the perceived quality of care offered by private and public providers differently, whereas this is not a topic in other contexts such as rural Mali where modern health services can only be found at state-sponsored dispensaries. In urban South Africa and Uganda, people value the availability of branded drugs, the medical security and health worker practice and conduct at the private clinics and ascribe higher levels of quality to these. However, in the study from Tanzania people reportedly have less trust in health workers who work for private for-profit institutions and have more trust in health workers in the non-profit sector, be it public or the faith-based facilities. Demonstrated empathy is important in several of the studies. Patients must be convinced that the providers actually care about their afflictions (Arborio, 2008; Gilson et al., 2005; Schneider, 2005). If the providers demonstrate empathy, cultural sensitivity and an understanding of social concerns, the communication will be more open and the patients will process information better (Thiede, 2005). These studies suggest that the public discussion about how to create demand for health services could benefit from including issues of perceived and enacted health worker empathy. The level of perceived fairness, respect and loyalty at the workplace between coworkers and between staff and managers appears to be crucial for the front line health workers’ motivation and job satisfaction (Dynes et al., 2013; Gilson et al., 2005; Scott et al., 2012). For the providers, it is a challenge to practice modern health care in a system in which the rules are poorly enforced, ethical behaviour is seldom rewarded by the management and where even the simplest diagnostic equipment are often lacking. These working conditions force the providers to improvise, to practice a different set of norms at work as compared to those which have been taught at medical school and challenge their professional identity (Martin, 2009; Wendland, 2010). Whereas most of the studies have focused on how people develop trust in the health systems through their interaction with the health workers, two studies have shown that in a situation where the formal organisation of the delivery of health services in government facilities is so inadequate and the safety of medical technology so insufficient that people do not only creatively develop other patterns of health seeking behaviours but also begin to distrust the public health sector (Birungi, 1998; Olsen, 2010). In health systems that for many reasons often fail to deliver better health, people cannot take quality of care for granted (Biehl & Petryna, 2013; Prince & Marsland, 2014). Yet, people make the leap of faith necessary to enter a health facility every day. The positive examples of trust show that trust functions as a means to reduce the complexity grafted upon health care, whereas the examples of mistrust illustrate how lack of trust adds to that complexity and leaves patients in a state of dependency. Interpreted together, the studies suggest that discretionary power exercised with fairness, perceived empathy, medical quality and workplace collegiality can facilitate trust
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in health sector relations. Trust is not only dependent on the providers’ medical expertise and communication skills, or on the reputation of the facility. Rather, it is connected to situations where people have reason to trust in the provider, the institution and the medico-technical equipment; where trust has become a routine over time and not a singular event; and where those in power actively reflect on how they can interact with those without power in the best possible way.
Conclusion: trust matters to global health The study of trust as practiced in health sector relationships has the potential to offer insights about ways to improve collaboration in the health sector. As the global health community moves forward in discussions of the post-2015 agenda, there is an increasing concern for improving health systems, knowing that the health care needs of a growing world population will put existing services under pressure (Duflo, 2010). This narrative review indicates that further exploration is needed to fully understand the relationship between trust and demand for health services. Many questions remain unanswered, but one stands out: how can we support health care actors – providers, patients and managers – in building positive expectations of each other, creating fertile ground for trusting relationships? The trust dividend from a better engagement between health providers and patients can potentially improve the demand for health services. This engagement could be strengthened through clearer accountability mechanisms for local health committees, better training of health workers’ relational and communication competencies and a focus by supervisors on how to create collegiality between providers and mid-level managers. Since trust is not a given, it will be repeatedly tested and must constantly be reaffirmed at all levels of the health care pyramid. If it is not, failed trust relationships may contribute to a breach between the people and the public system that is supposed to provide basic social services. In a situation in which the need to optimise the functioning of health service delivery is urgent, building trustworthy health systems is one way to move ahead. Acknowledgements I would like to thank Helle Samuelsen, Department of Anthropology, University of Copenhagen (UoC), Siri Tellier, Department of International Health, Immunology and Microbiology (ISIM), UoC, Tania Dræbel, ISIM, UoC, Britt Tersbøl, ISIM, UoC and Ole Nørgaard, UoC for their valuable observations during the preparation of the manuscript. I also wish to acknowledge the constructive comments by the three anonymous reviewers.
Disclosure statement No potential conflict of interest was reported by the author.
Funding This research was supported by Danida Fellowship Centre under the Danish Ministry of Foreign Affairs [grant number 11-014KU] as a part of the research project ‘Fragile Futures: Rural Lives in times of Conflict’.
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Note 1. As a part of the research project ‘Fragile Futures: Rural Lives in times of Conflict’, I conducted ethnographic fieldwork in Burkina Faso exploring how villagers utilise the public health system in remote areas.
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