Elsevier

Social Science & Medicine

Volume 61, Issue 7, October 2005, Pages 1418-1429
Social Science & Medicine

Trust and health worker performance: exploring a conceptual framework using South African evidence

https://doi.org/10.1016/j.socscimed.2004.11.062Get rights and content

Abstract

Two relationships of particular importance to health care provision are those between patient and provider, and health worker and employer. This paper presents an analytical framework that establishes the key dimensions of trust within these relationships, and suggests how they may combine in influencing health system responsiveness. The paper then explores the relevance of the framework by using it to analyse case studies of primary care providers in South Africa.

The analysis suggests that respectful treatment is the central demand of primary care service users, in terms of positive attitudes/behaviours, thoroughness, and technical competence, as well as institutions that support fair treatment. It is argued that such treatment is necessary for, and integral to, patient–provider trust. The findings also suggest that the notion of workplace trust (combining trust in colleagues, supervisor and employing organisation) has relevance to provider experiences of their workplaces, and so can provide important insights for strengthening management. Nonetheless, given the limitations of this preliminary analysis, further research is needed to develop the notion of workplace trust and to test what role it has, along with that of provider–community relations, in influencing health worker performance.

Introduction

Health worker performance is a much-neglected area of health system analysis in low- and middle-income countries. An important concern is the evidence from many settings, including South Africa, that public sector responsiveness is often undermined by poor health worker attitudes (Bassett, Bijlmakers, & Sanders, 1997; Jewkes, Abrahams, & Mvo, 1998; McPake, Asiimwe, Mwesigye, & Streefland, 1999).

This paper argues that the notion of trust offers a lens through which one can investigate these issues. Trust is central to debates about health systems in high-income countries (Mechanic, 2001; Welsh & Pringle, 2001), but has rarely been used in assessing health care provision elsewhere. Its importance to health systems lies in its potential to enable relationships that produce positive outcomes (Gilson, 2003).

The two key relationships on which this paper focuses are those between patient and provider, and health worker and employing organisation. The paper's main objective is to develop an analytical framework for investigating the role of trust in these two relationships, as an influence over health worker performance, from which management implications can be derived. The framework is presented in the following section and then its relevance is explored by using it to analyse case studies of primary care providers in South Africa in the subsequent three sections. Key conclusions are drawn in the last section.

Section snippets

Analytical framework

Trust is a complex construct, the specific elements of which vary between settings and relationships. Trusting another person or organisation always places the trustor in a situation of risk by leaving them vulnerable to the actions of the other (Coulson, 1998; Kramer, 1999). To trust requires the trustor to calculate or believe that the other will behave in ways that, at a minimum, do not cause her harm. Trust judgements are based on the combination of personal and institutional factors1

Overview of data presented in the paper

The data used in the paper are drawn from a study of the costs and quality of care South African primary care provider models undertaken in 1998/1999. The data relate to 22 case studies from three provider groupings: four private clinics (two private general practitioner (GP) clinics and two clinics belonging to a commercial clinic chain); seven public primary care facilities; and eleven contracted private providers (part-time district surgeons, PDS). Users of the private providers had higher

Patient/community views of providers

Patients’ overall judgements about private providers were nearly always positive: “They give people care and when you come from them you automatically feel better, because they treat you like a patient”. Central features of this experience were respectful attitudes (“they make you feel very important, even before you are treated”) and good communication (“the doctor has patience and he listens to everything that you tell him”). In addition, the technical competence of private doctors appeared

Discussion

In exploring the application of the analytical framework to these South African experiences, the three questions identified in the section “Analytical framework” are considered.

Conclusions

The findings presented in this paper suggest that respectful treatment is the central demand of South African primary care service users, understood in terms of positive attitudes/behaviours, thoroughness and technical competence, a well as institutions that enable fair treatment. Such treatment provides the basis for, and is integral to, patient–provider trust. The findings also suggest that the notion of workplace trust has relevance to South African health provider experiences. However,

Acknowledgements

Thanks to the other members of the team involved in the broader study reported here: Vishal Brijlal, Bongani Magongo, Anne Mills, Di McIntyre, Edina Sinanovic, Khethisa Taole, and Haroon Wadee. Thanks also to Gavin Mooney for comments on this paper. Lucy Gilson and Natasha Palmer are members of the Health Economics and Financing Programme of the London School of Hygiene and Tropical Medicine, which is supported by the UK Department for International Development (DFID). The views and opinions

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