A qualitative study of the role of workplace and interpersonal trust in shaping service quality and responsiveness in Zambian primary health centres

CITATION

Topp, S.M. & Chipukuma, J.M. (2016) A qualitative study of the role of workplace and interpersonal trust in shaping service quality and responsiveness in Zambian primary health centres, Health policy and planning, 31(2), 192-204

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ABSTRACT
Background: Human decisions, actions and relationships that invoke trust are at the core of functional
and productive health systems. Although widely studied in high-income settings, comparatively
few studies have explored the influence of trust on health system performance in low- and
middle-income countries. This study examines how workplace and inter-personal trust impact service
quality and responsiveness in primary health services in Zambia.
Methods: This multi-case study included four health centres selected for urban, peri-urban and
rural characteristics. Case data included provider interviews (60); patient interviews (180); direct
observation of facility operations (two weeks/centre) and key informant interviews (14) that were
recorded and transcribed verbatim. Case-based thematic analysis incorporated inductive and
deductive coding.
Results: Findings demonstrated that providers had weak workplace trust influenced by a combination
of poor working conditions, perceptions of low pay and experiences of inequitable or inefficient
health centre management. Weak trust in health centre managers’ organizational capacity
and fairness contributed to resentment amongst many providers and promoted a culture of blameshifting
and one-upmanship that undermined teamwork and enabled disrespectful treatment of
patients. Although patients expressed a high degree of trust in health workers’ clinical capacity,
repeated experiences of disrespectful or unresponsive care undermined patients’ trust in health
workers’ service values and professionalism. Lack of patient–provider trust prompted some
patients to circumvent clinic systems in an attempt to secure better or more timely care.
Conclusion: Lack of resourcing and poor leadership were key factors leading to providers’ weak
workplace trust and contributed to often-poor quality services, driving a perverse cycle of negative
patient–provider relations across the four sites. Findings highlight the importance of investing in
both structural factors and organizational management to strengthen providers’ trust in their
employer(s) and colleagues, as an entry-point for developing both the capacity and a work culture
oriented towards respectful and patient-centred care.


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