Using Theories to Frame Research Studies
Barras
czv041.pdf
A qualitative study of the role of workplace and
interpersonal trust in shaping service quality
and responsiveness in Zambian primary health
centres
Stephanie M Topp1,2,3,* and Julien M Chipukuma4
1Schools of Public Health and Medicine, University of Alabama, Birmingham, USA, 2Centre for Infectious Disease
Research in Zambia, PO Box 30338, Lusaka, Zambia, 3Nossal Institute for Global Health, University of Melbourne,
Level 4, 161 Barry Street, Alan Gilbert Building, Carlton 3010, VIC, Australia and 4University of Lusaka, Plot No
37413, Mass Media, Lusaka 101010, Zambia
*Corresponding author. Centre for Infectious Disease Research in Zambia, PO Box 30338, Lusaka, 10101, Zambia.
E-mail: [email protected]
Accepted on 14 April 2015
Abstract
Background: Human decisions, actions and relationships that invoke trust are at the core of func-
tional and productive health systems. Although widely studied in high-income settings, compara-
tively 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 ser-
vice 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 combin-
ation of poor working conditions, perceptions of low pay and experiences of inequitable or ineffi-
cient health centre management. Weak trust in health centre managers’ organizational capacity
and fairness contributed to resentment amongst many providers and promoted a culture of blame-
shifting 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.
Key words: Health systems, primary health care, service delivery, trust
VC The Author 2015. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact
Health Policy and Planning, 31, 2016, 192–204
doi: 10.1093/heapol/czv041
Advance Access Publication Date: 20 May 2015
Original article
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Background
Within the global health fraternity, there is growing recognition of
the ‘people-centredness’ of health systems (Sheikh et al. 2014a,b).
Despite this, the role of human relationships within health systems
and the factors that influence their development remain poorly
understood. Guided by functionalist constructs including the six
World Health Organization (WHO) health system building blocks,
health systems research in low- and middle-income countries
(LMICs) in particular, has tended to focus on the material compo-
nents of health systems or, where human factors are considered, in-
tellectual capabilities (World Health Organization 2007; Atun and
Menabde 2008; van Olmen et al. 2012). One encouraging exception
to this trend, however, is a small but growing body of literature
focusing on trust as a lens for examining the way human relations
influence and are influenced by health system functioning in LMIC
(Goudge and Gilson 2005; Svedin 2012).
Hall et al. (2001) characterize trust as ‘the optimistic acceptance
of a vulnerable situation in which the trustor believes the trustee will
care for their interest’. To date, much of the scholarly work on trust
has focused on three main constructions of the concept, namely per-
sonal, inter-personal and impersonal trust (Taylor 1989; McKnight
and Chervany 1996). Explorations of personal trust include examin-
ations of strategic behaviour (Creed and Miles 1996; Gambetta
2000) or the ways in which an actor assesses the relative risks versus
potential gains from trusting another person. Others have examined
personal trust as a product of altruism, rooted in the morally worthy
behaviour of actors who perceive intrinsic value in acting in others’
interests (Mansbridge 1999; Ulsaner 1999).
As discussed by Gilson et al. (2005b),Wuthnow (2004) theorize
that inter-personal trust is not only based on judgements of compe-
tency but also on assessments of a third party’s reliability, sincerity,
generosity and fairness. Inter-personal trust has also been demon-
strated to be time-sensitive, strengthening or weakening over time as
a result of repeated interactions that produce cumulative judgements
about, and expectations of, certain behaviours. Where the inter-
actions are positive, Lewicki and Bunker (1996) note that such en-
gagement can contribute to the generation of common norms and
shared values.
Related to inter-personal trust and sharing many similar features,
explorations of impersonal trust have included studies examining
the links between trust and natural or unconscious dispositional
traits such as shared identity (e.g. nationality) (Putnam 1993) or on
repeated interactions between relative strangers (Mayer et al. 1995).
In health systems, where interactions between relative strangers are
a common occurrence, impersonal trust is critical. In such settings,
impersonal trust may be fostered by institutions that provide the
nominal basis for trusting strangers such as defined organizational
roles or legal frameworks that enable monitoring and evaluation of
performance (Warren 1999) or by professional or technical institu-
tions that generate and protect knowledge such as medical licensure
(Giddens 1990).
Even in the case of impersonal trust, however, repeated inter-
personal interaction will likely play an important role. Indeed, a ser-
ious complicating factor in the generation of impersonal trust is
whether the ‘trustee’ has the material capability to meet the expect-
ations of the ‘truster’, especially where the former is dependent on a
range of enabling factors (e.g. resources or service environment) that
lie outside their direct control (Tendler 1997). In such circum-
stances, mechanisms of accountability operating at multiple levels to
enable the generation of impersonal trust are likely to take on par-
ticular significance.
Trust in health care and health systems Various studies have demonstrated that trust is linked to important
health-care objectives including access, utilization (Russell and
Gilson 2006), satisfaction (Safran et al. 1998), information dissem-
ination and effectiveness (Hall et al. 2001). Some recent studies have
also suggested that trust is associated with improved self-reported
health status (Wang et al. 2009). Empirical research from high-
income settings has tended to focus on patient–provider trust, inves-
tigating, among other areas, ‘cues’ of trustworthiness (Anderson and
Dedrick 1990; Mechanic 1996; Thom and Campbell 1997), and the
role of institutions and structures such as ethical codes, training
standards and regulatory mechanisms for improving patient–
provider trust (Campbell 1996; Rothstein 1998; Straten et al. 2002).
A more limited body of work has explored the concept of distrust.
Mascarenhas et al. (2006) argue that ‘distrust is a qualified [or] con-
ditional trust in doctors and/or the health care delivery system on
the part of the patient’ arising from a range of factors including cost,
the difficulty of navigating the health system, pre-existing anxiety
and previous negative encounters within the health system. The au-
thors suggest that distrust can co-exist with trust during patient–
physician encounters.
Despite growing recognition that the human decisions, actions
and relationships that invoke trust lie at the core of any productive
social system, only a handful of studies have focused on trust in the
health systems of LMIC. Based on a mixed methods study, Gilson
(2005) and Gilson et al. (2005a) examined the role of trust in
Key Messages
• Findings demonstrated that providers had weak workplace trust influenced by a combination of poor working condi- tions, 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 blame-shifting and one-upmanship that undermined teamwork and enabled disres-
pectful treatment of patients. • Although patients expressed a high degree of trust in health workers’ clinical capacity, repeated experiences of disres-
pectful 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. • Findings point to the need for investment in both structural/material improvements and organizational management to
strengthen providers’ trust in their employer(s) and colleagues, as an entry-point for shifting primary health service
work culture towards more respectful and patient-centred care.
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provider performance and patient–provider interactions in South
African primary health centres (PHCs) concluding that ‘workplace’
and ‘patient–provider’ trust are influenced by multiple and overlap-
ping factors. The important role of patient–provider trust as a driver
of health seeking behaviour among patients in a hospital setting in
Colombo, Sri Lanka was outlined by Russell (2005), while in
Tanzania, Tibandebage and Mackintosh (2005) explored the effects
of system-wide mistrust and the associated expectation of abuse
and/or exclusion on patients’ psycho-social well-being and financial
status. Relatedly, Gilbert (2005) demonstrated that trust is influ-
enced by professional norms and power dynamics between nurses
and doctors. A recent review of quantitative measures of trust used
in both the developed and developing world concluded that the
focus of the published literature remains narrow (predominantly ad-
dressing patient–provider trust) and geographically skewed in fa-
vour of high-income settings (Ozawa and Sripad 2013).
The study presented in this article was premised on the idea that
trust offers an important lens through which to understand service
practices in primary-level health centres. Our aim was to examine
the relevance of and factors contributing to the production of trust,
and related, the influence of trust (or its absence) on the quality and
responsiveness of service delivery in a low-resource setting.
Methods
Study setting Zambia’s health system at the time of study was comparatively cen-
tralized with the Ministry of Health (MOH) responsible for national
health policies as well for direct oversight of tertiary hospital oper-
ations. A network of 1500 PHCs, first- and second-level hospitals
were overseen by Provincial and District Health Offices, respect-
ively. As at 2011, PHCs made up the majority (79%) of Zambia’s
health facilities, with �29% of these located in urban areas. According to the Zambian MOH, urban PHCs serve a catchment
population of 30 000 to 50 000 while rural PHCs serve a population
of up to 10 000 [MOH and Government of the Republic of Zambia
(GRZ) 2007]. Depending on location and the centralized allocation
of district resources, urban and rural health centres may include vari-
ous combinations of the following ‘departments’: outpatient depart-
ment (OPD), inpatient department (IPD), maternal and child health
department (MCH), labour ward, tuberculosis treatment department
(TB corner), HIV care and treatment department (HIV department or
sometimes ‘antiretroviral clinic’), laboratory and environmental
health team. The typical administrative structure of PHCs is outlined
in Figure 1, with health centre activities overseen by an ‘overall in-
charge’ who is deputized by a series of ‘departmental in-charges’. All
such appointments are made at the district level.
Conceptual framework The study formed part of a larger research project that investigated
how interactions between ‘hardware’ and ‘software’ components
of the health system shaped the service patterns in four Zambian
PHC (see: Topp et al. 2015). The larger study was guided by the
mechanisms of effect framework, which suggests that in micro-
health systems, people-centred mechanisms such as trust and
accountability provide important lenses through which to
Figure 1. Typical administrative structure for a Zambian primary health centre
OPD, outpatient department; MCH, maternal and child health department; ART, antiretroviral (for HIV); TB, tuberculosis; EHT, environmental health technologist
! Solid-line arrows indicate lines of authority from the top down
— Dotted lines indicate lay or auxiliary workers with positions sanctioned but not officially financed by MOH
194 Health Policy and Planning, 2016, Vol. 31, No. 2
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understand service quality and responsiveness. Mechanisms of trust
and accountability are in turn the localized product of interactions
between health system ‘hardware’ and ‘software’ but may also
evolve to become properties of the system as a whole (Topp et al.
2014).
The focus of this study was explicitly on mechanisms of trust in
the primary health care domain, with previous published work
examining the role of accountability in the same setting (Topp et al.
2014). Guided by Gilson et al.’s (2005b) trust framework our re-
search focused on two key dimensions of trust: workplace trust and
patient–provider trust. Workplace trust was understood to be the
product of health-care providers’ trust in their employer, supervisors
and colleagues. Workplace trust was also conceptualized as an im-
portant determinant of providers’ motivation and client orientation,
which in turn influenced patient–provider trust. Patient–provider
trust was theorized to be the product of patients’ and providers’ in-
ter-personal trust (trust in each other), and their trust in health sys-
tem institutions, including health worker qualifications. A summary
of these domains is listed in Table 1.
Study aim The aim of this study was to examine how workplace trust and pa-
tient–provider trust influenced the quality and responsiveness of ser-
vice delivery in four Zambian health centres. Our specific objectives
were to (1) test the relevance of the concepts of ‘workplace trust’ and
‘patient–provider trust’ in the Zambian setting; (2) understand the fac-
tors influencing the production of these different types of trust and (3)
explore whether and how workplace and patient–provider trust inter-
act in the Zambian primary health-care setting and with what effect.
Study design A multi-case design with a theoretical replication strategy (Yin 2009)
was adopted. Four PHCs (PHC1–PHC4) each representing a case
unit were purposively chosen from two districts within Lusaka
Province. Selection was based on established (>36 months) HIV care
and treatment service1 and a catchment population characterizing
the PHC as a large urban facility (>100 000), small urban facility
(40 000–70 000), peri-urban facility (<40 000) or rural facility
(<30 000), respectively. A list of all facilities in the districts that fit-
ted the criteria was initially developed, and case selection was con-
ducted in collaboration with District Medical Officers and local
colleagues accounting for both logistical issues and accessibility.
Final selection was subject to the informed consent of each PHC in-
charge.
Data were collected between June and December 2011. Data col-
lection methods included in-depth interviews with a proportionate
sample of health-care workers from all health centre departments
(n¼60); structured observations and semi-structured interviews (conducted post-consultation/observation) with a quasi-random
sample of patients (n¼180); review of health centre paper-based registers; and direct unstructured observation of facility operations
(2–3 weeks per site). Structured observations focused on recording
explicit activities (e.g. medical history, physical examination, blood
draw, etc) and the type of information exchanged between health
workers and patients during routine screening visits in the outpa-
tient, MCH, TB and HIV departments. Unstructured observations
were guided by a note-taking tool developed from the conceptual
framework and included notes on informal discussions and inter-
actions. We additionally conducted key informant interviews with
government and non-government officials (n¼14) with specific knowledge or experience in front line supervision. Table 1 outlines
the sampling approach and rationale for each data collection
method and summarises the number of activities conducted at each
site.
In interviews with providers and patients, the term trust was not
explicitly introduced due to the risk of social desirability bias
(Krumpal 2013). Prior experience of conducting interviews
in Zambian health centres (Topp et al. 2010; Topp et al. 2013)
indicated that when asked direct questions about interpersonal inter-
actions, both patients and providers tended to provide undifferenti-
ated and affirming descriptions of their relationships. This, despite
observations of inter-cadre and patient–provider tension suggest a
more complex set of relationships. In this study, therefore, questions
were designed to elicit detailed descriptions of interactions among
and between staff and patients to provide insight into whether and
why trust may be present in certain relationships, without necessar-
ily asking directly about ‘trust’. Themes that were explored in rela-
tion to workplace trust included perceptions of support and
collegiality between health providers and towards supervisors and
district managers, providers’ confidence that their professional ex-
pectations would be met and providers’ willingness to rely or depend
on their colleagues or managers under different conditions. In rela-
tion to inter-personal trust particular attention was paid to expres-
sions of faith in providers’ good will; patients’ confidence that
providers were adequately skilled and their hope versus expectations
of receiving timely and good quality services. These responses were
then triangulated with direct observations of inter-personal inter-
actions to provide a better understanding of the way workplace trust
and patient–provider trust influenced day-to-day operations.
The primary investigator conducted all the health worker inter-
views in English. Patient interviews were conducted by one of the
two trained research assistants in the participants’ choice of English,
Nyanja or Bemba. All interviews were conducted in private rooms
in the health centres. Written informed consent was obtained from
all participants (patients, providers and key informants) for any ob-
servations or interviews. The study received ethical clearance from
the authors’ local institutes.
Analysis was carried out in three phases. Phase one was con-
ducted concurrently with data collection, as collated notes and sum-
maries of evidence were generated for each health centre.
Transcribed interviews were imported into NVivo QSRTM for elec-
tronic coding. In phase two, data were organized to produce a case
description for each health centre (Yin 2009). Qualitative and obser-
vational data were synthesized and compared with develop as com-
prehensive a picture as possible of the operational reality at each
site. This phase included comparison and cross-checking of all data
to generate cohesive and consistent case descriptions and to identify
unusual or exceptional experiences. Preliminary case descriptions
were disseminated to the health-centre managers and district med-
ical officers to garner feedback. Phase three focused on cross case
comparisons using both deductive and inductive analysis. Deductive
analysis was guided by codes developed from the conceptual frame-
work including system hardware (e.g. financing, human resourcing,
drug supplies); system software (leadership, workplace norms, pa-
tient expectations); workplace trust (employer, supervisor, col-
leagues) and patient–provider trust (inter-personal, institutional).
Coded text and its (anonymized) source were collated in a word
document and printed to enable synthesis of major findings relating
to hardware–software interactions and their impact on mechanisms
of effect within the health centres. Theoretically generated codes
were supplemented with inductive codes, and commonalities identi-
fied across the four cases. Negative case analysis was conducted
through the identification of experiences or interactions that
Health Policy and Planning, 2016, Vol. 31, No. 2 195
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T a b
le 1 . S
u m
m a
ry o
f d
a ta
c o
ll e
c ti
o n
a n
d s a
m p
li n
g a
t fo
u r
P H
C s
M et
h o d
S o u rc
e S a m
p li n g
a p p ro
a ch
R a ti
o n a le
fo r
d a ta
co ll ec
ti o n
P H
C 1 a
D a te
s:
1 – 2 1
Ju n e
2 0 1 1
P H
C 2 a
D a te
s:
2 6
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1 5
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2 0 1 1
P H
C 3 a
D a te
s:
3 – 1 9
O ct
. 2 0 1 1
P H
C 4 a
D a te
s:
1 1 – 2 5
N o v . 2 0 1 1
T o ta
l
N u m
b er
o f
a ct
iv it
ie s
co n d u ct
ed
D ir
e c t
o b se
rv a ti
o n s
F a ci
li ty
a u d it
D es
ig n ed
to p ro
v id
e a
sn a p -s
h o t
o f
p h y si
ca l,
m a te
ri a l a n d
a d m
in is
tr a ti
v e
st ru
ct u re
s in
p la
ce . C
o n d u ct
ed w
it h
fa ci
li ty
in -c
h a rg
es .
1 1
1 1
4
U n st
ru ct
u re
d
o b se
rv a ti
o n s
a n d
re se
a rc
h
m em
o s
2 w
ee k s
p er
fa ci
li ty
C o n tr
ib u te
d to
b u il d in
g a
p ic
tu re
o f
ty p ic
a l w
o rk
fl o w
s a n d
h u m
a n
in te
ra ct
io n s
th a t
in fl u en
ce d
h ea
lt h
ce n tr
e o p er
a ti
o n s.
P ro
v id
ed im
p o rt
a n t
d a ta
to su
p p le
m en
t st
ru ct
u re
d h ea
lt h
ce n tr
e a u d it
s a n d
d ir
ec t
o b se
rv a ti
o n
o f
p a ti
en t
v is
it s.
3 w
ee k s
2 w
ee k s
2 .5
w ee
k s
2 w
ee k s
n /a
S tr
u ct
u re
d
o b se
rv a ti
o n s
Q u a si
-r a n d o m
sa m
p li n g
(e v er
y th
ir d
q u eu
in g
p a ti
en t
a p p ro
a ch
ed to
p a rt
ic ip
a te
o n
sp ec
ifi ed
o b se
rv a ti
o n
d a y s
fo r
ea ch
d ep
a rt
m en
t) . In
te rv
ie w
s in
a ll
a ct
iv e
P H
C d ep
a rt
m en
ts w
it h
a m
in im
u m
o f
ei g h t
p a ti
en ts
p er
d ep
a rt
m en
t.
P ro
v id
ed ev
id en
ce o f
th e
a ct
u a l ca
re
p a th
w a y s
a n d
w a it
in g
ti m
es in
v o lv
ed
a n d
th e
n a tu
re o f
p a ti
en t–
p ro
v id
er
in te
ra ct
io n s
a cr
o ss
a ll
m a jo
r
d ep
a rt
m en
ts . T
h is
ev id
en ce
p ro
v id
ed a
q u a n ti
fi a b le
b a si
s fo
r co
m p a ri
n g
p a ti
en t
a n d
p ro
v id
er p er
ce p ti
o n s
o f
h ea
lt h
ce n tr
e se
rv ic
e o p er
a ti
o n s
4 7
4 8
4 6
4 4
1 8 5
In te
rv ie
w s
H ea
lt h
ca re
w o rk
er s
P ro
p o rt
io n a l (r
el a ti
v e
to
d ep
a rt
m en
ta l st
a ff
n u m
b er
s)
p u rp
o si
v e
sa m
p li n g
to in
cl u d e
o v er
a ll
a n d
d ep
a rt
m en
ta l
in -c
h a rg
es , a n d
a t
le a st
o n e
a ct
iv e
st a ff
m em
b er
fr o m
a ll
d ep
a rt
m en
ts . M
in im
u m
tw o
in te
rv ie
w s
p er
d ep
a rt
m en
t
co n d u ct
ed in
u rb
a n
P H
C s.
In te
rv ie
w s
w er
e b u il t
a ro
u n d
fo u r
m a jo
r
th em
es ; (1
) p ro
v id
er s’
ro le
in th
e
h ea
lt h
ce n tr
e, th
ei r
ty p ic
a l ro
u ti
n e
a n d
th ei
r p o si
ti o n
in re
la ti
o n
to o th
er s
in
th e
fa ci
li ty
; (2
) th
e ch
a ll en
g es
fa ce
d in
d a y -t
o -d
a y
w o rk
; (3
) p er
ce p ti
o n s
o f
th e
w o rk
p a tt
er n s
a n d
w o rk
cu lt
u re
in
th e
fa ci
li ty
, in
cl u d in
g th
e ro
le o f
h ea
lt h
ce n tr
e m
a n a g er
s; (4
) th
ei r
u n d er
st a n d in
g o f,
a n d
a tt
it u d es
to w
a rd
s, th
e in
tr o d u ct
io n
o f
H IV
se rv
ic es
.
2 3
8 1 6
1 7
6 4
P a ti
en ts
C o n d u ct
ed w
it h
th e
sa m
e p a ti
en ts
w h o
co n se
n te
d to
p a rt
ic ip
a te
in th
e st
ru ct
u re
d o b se
rv a ti
o n
ex er
ci se
— sa
m p le
o u tl
in ed
ea rl
ie r.
Q u es
ti o n s
d es
ig n ed
to p ro
v id
e a n
in si
g h t
in to
th e
p a ti
en t’
s re
a so
n s
fo r
a tt
en d in
g
th e
cl in
ic , th
ei r
p er
ce p ti
o n s
a b o u t
w h a t
h a p p en
ed d u ri
n g
th e
v is
it , th
ei r
u n d er
st a n d in
g o f
p ro
ce ss
es a n d
re la
ti o n sh
ip s
d ri
v in
g se
rv ic
e d el
iv er
y ,
a n d
h o w
p ro
v id
er b eh
a v io
u r
a n d
se rv
ic es
m et
th ei
r ex
p ec
ta ti
o n s.
4 7
4 8
4 6
4 4
1 8 5
a P H
C , p ri
m a ry
h ea
lt h
ce n tr
e
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appeared to contradict the theoretical assumptions underpinning
this study. Results and discussion presented in this article draw pri-
marily on in-depth provider interviews and semi-structured patient
interviews but are critically informed by in-person observations and
key informant interviews.
Findings
Using Gilson et al.’s (2005) framework as a guide, we present findings
in two sections focussing on workplace trust and patient–provider
trust, respectively. Within each section, we outline factors influencing
providers’ or patients’ trust and distrust in the health system and sub-
sequently describe how these factors influenced service quality or re-
sponsiveness. Consideration of the influence of health system
hardware and software is integrated into each section, while explor-
ation of how workplace trust and patient–provider trust interact is ad-
dressed in the Discussion. Study sites or primary health centres are
referred to as PHC1, PHC2, PHC3 and PHC4 respectively.
Relevance of and factors influencing workplace trust We found the concept of workplace trust to be highly relevant to the
Zambian PHC setting with a range of factors contributing to gener-
ally weak trust in employer, supervisor and colleagues, respectively.
Trust in employer
Four common themes were identified across the four sites as influenc-
ing trust in employer amongst the Zambian public health workers
(Table 2). The first was inadequate or delayed remuneration, with
many providers complaining about insufficient pay. A number add-
itionally commented on problems to do with the timeliness of payment
Our pay, it is something else. Especially here in Lusaka, it doesn’t
go very far. The government should just consider giving us what
we need. Nurse, PHC4.
Payments come late and [although the Ministry] always promise,
‘it is coming,’ it’s a challenge. Nurse, PHC1.
Human resource shortages and associated workload were a se-
cond theme related to providers’ trust in their government employer.
Respondents frequently attributed staff shortages to the need for the
MOH to hire more people or the need for better-qualified staff.
Others expressed frustration with having to take on extra duties or
responsibilities (experiencing ‘duty creep’) as a result of health
centres being short-staffed.
I want the Ministry to send people who are qualified [ . . . ], not
someone who can only deliver half the services. Overall In-
Charge, PHC2.
A nurse should just be nursing. But you find that . . . I have to do
data, I am a lab tech and I have to do the counselling. So I’m
doing five [sic] people’s jobs. Nurse, PHC3.[2]
In the rural PHC, where government housing is an established
benefit of the post, several providers expressed frustration based on
the perception that the MOH used lack of staff housing as an excuse
to avoid allocating the full complement of staff:
If [the Ministry] built us more [staff] houses then [it] would not
give us that excuse: ‘there is no accommodation so why allocate
staff?’ Nurse, PHC2.
A third common theme related to providers’ trust in their em-
ployer was sub-optimal working and/or environmental conditions.
Such concerns were focused on drug or equipment shortages and
most commonly raised by providers working in the OPDs of the
urban facilities. Critically, drug and commodity shortages were per-
ceived to be reflective of a more systematic breakdown in Ministry-
and District-administered supply chains.
Supplies are never enough. Nurse, PHC1.
Drug shortages are constant; we are always running out of this
or that. Nurse, PHC3.
Here we push our [pharmacy] orders [ . . . ] but it takes time and
[we] often find that what [we] ordered hasn’t come. But, it’s diffi-
cult to know whether the issue is with [the stocks in] Medical
Stores or if [the problem] is no District transport for delivery.
[Another problem] is if Medical Stores don’t have enough [drugs]
to begin with, they [provide] less to the District and then the
District just decides how much [each health centre] gets;
LabTech, PHC 3.
A final theme emerging in relation to providers’ trust in employer
was that of inadequate administrative and supervisory support. This
concern was most emphatically expressed by providers at the rural
facility (PHC 2) where the professional staff who were interviewed
expressed anxiety about the lack of District support including the
nurse who was dually in-charge of the outpatient and HIV
departments:
I don’t feel I am getting support [from the District]. It’s not ad-
equate. [ . . . ] I am all alone. Nurse, PHC2.
Table 2. Factors influencing workplace trust in four Zambian health centres
Workplace trust
Sub-category Dimension of trust or mistrust Themes arising from data Hardware–software factors
Trust in employer System trust
Fidelity
Insufficient/delayed pay
Unmet professional expectations
Poor work conditions
District/MOH support
HCW identity as ‘underpaid’ civil servant
Under-resourcing
Limited professional development
Trust in supervisor Competence
Communication
Fairness
Weak transparency
Lack of consistency
Weak problem solving capacity
Ad hoc information sharing
Weak leadership capacity
Orientation fatigue
Frequent staff turnover
Weak mechanisms of
administrative accountability
Trust in colleagues Honesty
Communication
Fairness
Weak accountability
Unequal conditions of service
Erosion of service values
Weak sense of teamwork
High stress environment
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In the urban and peri-urban health centres, staff reported a more
supportive District presence. However, complaints related to per-
ceptions of weak support from provincial or ministry-level officials
remained common.
The District is supportive and understands. There are meetings
and performance assessments. [They] will call or visit to find out
how you are going; Nurse, PHC3.
Rarely, if ever, do the Ministry come to see us, to see what we
need. So how can they look after us? In-Charge, PHC1
Trust in supervisor
Trust in supervisor was an important theme emerging from both
interview and unstructured observational data across the four sites
and was influenced by three common factors (Table 2). The first
was a perception amongst providers that overall or departmental in-
charges did not behave fairly or consistently. In PHC1, PHC3 and
PHC4 this concern was focused on the issue of selection for inclu-
sion in workshops or in-service training opportunities, with various
staff implying that in-charges’ decisions about who was selected for
these sought-after opportunities were arbitrary and lacking
transparency:
I see a bit of a problem [with management] to be honest. There
are some people who are sidelined when it comes to trainings.
Nurse PHC3.
If you are friendly with the [manager] maybe you are given
opportunities. But if you are not friendly you just get passed
over. Nurse, PHC1.
A second theme related to trust in supervisors was problem-solv-
ing capacity. Frustrations with overall and departmental in-charges’
perceived inability to address ongoing material shortfalls in the
health centres were common. Although many respondents acknowl-
edged the backdrop of general resource shortages, a number also
suggested that health centre managers used these resource and finan-
cial constraints as an excuse for their own local inaction:
The answer is always: ‘no funds’. It’s a scapegoat. Sometimes it’s
true, [but] if the issue has not been communicated to the District
or somewhere else that’s why the same issues keep coming up;
Nurse, PHC3.
Poor communication and information dissemination constituted
a third theme related to trust in supervisors. As noted earlier, lack of
transparency around the selection for in-service trainings was a com-
mon complaint, contributing to many providers’ suspicion of their
supervisors’ motives.
There is no way of knowing how people are selected [for train-
ings] – we are not told why. Nurse PHC4.
But in-clinic observations also demonstrated generally ad hoc
approach to intra-facility information sharing, exemplified by the ir-
regular scheduling of nominally compulsory ‘monthly’ staff meet-
ings. Such weak information sharing was partly related to the high
rate of health-care worker and in-charge turnover, which in turn
exacerbated the need for information transfer and added to ‘orienta-
tion fatigue’.
Trust in colleagues
Two major themes relating to providers’ trust in their colleagues
emerged from interviews and observation data (Table 2). Belying
providers’ initial descriptions of the solid teamwork within the facil-
ity, observations of heavily siloed work-operations and providers’
own complaints about the impact that other staff-members’ (sub-
standard) work practices had on their own performance suggested a
perceived lack of accountability among members of staff in ‘other’
departments or ‘other’ cadres.
If these clinical officers were found there doing their job, we [in
the lab] would also be able to do our jobs; Lab Tech, PHC3.
The nurses don’t do their jobs. They’re meant to triage the com-
plex cases to send to us, but they just take the temperature and
send all the patients on; Clinical Officer, PHC4.
[Clinical Officers] are sometimes lazy, and then the patients
shout as us [nurses] for being slow but there is nothing we can
do; Nurse, PHC1.
Underpinned by widespread perceptions of underpay and over-
work (see earlier), a second theme related to trust in colleagues was
the perception that providers operating in different departments
were somehow advantaged.
These others [in the outpatient department], they have morning
and afternoon shifts. So by midday they change shift and the new
ones that come are fresh. But for us [in maternal and child health
department] we work morning to evening. Midwife, PHC3.
Notably, we found fewer concerns about comparative profes-
sional or financial advantage, and much stronger expressions of
trust amongst providers in the smaller rural facility (PHC2) where
both professional and lay provides described a culture of mutual re-
spect and teamwork. This was supported (for the most part) by dir-
ect observation. Professional staff indicated that the shared
experience of operating in a small, understaffed clinic with on-site
housing contributed to a sense of team bonding. This, in combin-
ation with the flat management structure and a perceived reduction
in status differences associated with constant task-shifting appeared
to contribute to the greater degree of tolerance amongst colleagues.
The influence of workplace trust on service quality and
responsiveness Weakening of individual work ethic and an undermining of provider
teamwork constituted the most obvious effects of these workplace
trust factors on service quality and responsiveness. In relation to sal-
ary levels and the consistency of payment, for example, many pro-
viders described a general lack of motivation underpinning their
own individual, as well as team performance.
There are no incentives to motivate the workers. Nurse, HC4.
Really you just have to appreciate yourself, because if you were
relying on the government [ . . . ] to appreciate you, then you
would always feel frustrated. They don’t care. Nurse, PHC3.
Some providers linked the perception of poor pay to their deci-
sion to seek additional paid work (‘moonlighting’) to supplement
their income, acknowledging that this practice often left health
centres even more short-staffed than before. Others described how
the perceived lack of financial incentive also directly influenced their
attitude and responsiveness to patient needs.
If I got enough money from [this job], it would be satisfying. But
I don’t get enough, so I have to look for other sources. Nurse,
PHC1.
When you motivate someone financially, even if they do not have
all the equipment they need, they would just find a way to help
out. But without that [financial incentive] they relax. For ex-
ample, there are times when we run out of these TB sputum con-
tainers here in the lab. If truly I were motivated financially,
I would go out of my way to go out there and ask for these
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containers from other clinics. Or I would come and help out the
other patients. But when there is nothing like that I just say “go
elsewhere.” Lab Tech, PHC3.
Also affecting workplace motivation in the two urban health
centres (PHC1, PHC3) were concerns for personal health and safely,
as interviews with nurses, clinicians and laboratory technologists
revealing common concerns about the way overcrowding and inad-
equate physical infrastructure increased their risk of exposure to in-
fectious diseases
The clinic is over-crowded and you can get diseases. Like right
now I am not feeling well. I am feeling very sick and I’m worried.
It might be anything. Clinical Officer, HC3.
If you look at our environment it is not conducive to operate
from. They [the Ministry] should do something about that.
Nurse, PHC1.
Weak motivation and poor work performance were also linked
by many professional health workers to their lack of trust in super-
visors or colleagues. Supervisors’ apparently arbitrary decision mak-
ing, weak information dissemination and associated perceptions of
favouritism or unfair advantage gained by their colleagues, were all
factors listed as affecting motivation to perform well or even just to
standard.
You see that favouritism and it is demoralising; Nurse, PHC1.
There is no way of knowing how people are selected – we are not
told why. Even when you work so hard you might be overlooked.
Nurse, PHC4.
Lack of resolution on outstanding health centre systems issues or
in-charges’ unwillingness to tackle perverse work norms (e.g. tardi-
ness and absenteeism) were also linked to a sense of futility in some
providers’ efforts to remain positive and deliver good care.
There are challenges that come up almost every month and they
are not resolved; we just talk about them again and again. It
makes you feel low. Nurse, PHC3.
In all facilities, providers’ frustration with their workload was
linked to a sense of their diminished capacity to deliver quality care
and in turn, feelings of frustration or inadequacy that provoked in-
appropriate behaviour towards their patients.
Drug shortages are always a challenge. All the things we use like
[thermometers, blood pressure cuffs], we always run out of these
things. Nurse, PHC1.
When you ask the patient to go and buy drugs [at an external
pharmacy] they don’t understand why. And I cannot explain
properly so I just tell them off, even though I know they are cor-
rect, I should have the drugs. Nurse, PHC3.
Similarly, the issue of human resource shortages was strongly
linked to weaker individual performance and to less positive patient
orientation.
It’s too much for me [ . . . ] I find that I am not doing quality
work. Nurse, PHC2.
You touch here, you touch there, you go give an injection, but
you are not concentrating. Clinical Officer, PHC3.
Relevance of and factors influencing patient–provider
trust As outlined below our findings demonstrate the relevance of pa-
tient–provider trust to the Zambian PHC setting with a number of
contributing factors.
Institutional trust
We found mixed, but generally positive perceptions in relation to
patients’ institutional trust in providers, with a majority of those
interviewed expressing confidence that professional health workers
were qualified and clinically competent. Clinical officers and med-
ical officers, in particular, were described as having the training to
‘examine me properly’ and ‘give me the right medication for my ill-
ness’. In response to the question: ‘which health care provider would
you prefer to see?’ patients most often expressed a desire to be
examined ‘by the doctor’ giving reasons like the doctor (clinical or
medical officer) can ‘cure me’ or ‘solve my problems’.
The doctor is the only person I want to see. If he is examining
you, you know that he will give you the right treatment; OPD
Patient, PHC2.
Notwithstanding these affirmations, patients’ institutional
trust was often undermined by repeated experiences of unresponsive
or even abusive staff (see next section). While many patients
described professional health workers as ‘experts’, for example, they
simultaneously criticized provider performance as ‘not up to
expectation’.
Interestingly, patients from all four clinics expressed far less ‘in-
stitutional’ confidence in lay health workers, with the main reason
being their lack of, or lower-level qualifications.
A lot of people who work here are just volunteers from the vil-
lages and sometimes act like they are qualified which is not good;
OPD Patient, PHC2.
However, patients’ accounts of their inter-personal experiences
with these same lay staff were more often positive, especially by
comparison to descriptions of patient interaction with professional
health workers. This phenomenon was most clear in health centres 1
and 2 where peer educators who had been delegated responsibility
for TB treatment and support services were referred to by patients’
as ‘doctor’ despite understanding that these staff members were not
formally qualified.
The ones here, they really have a heart. They provide the infor-
mation and they are patient with us. TB Patient, PHC1.
Inter-personal trust
Inter-personal trust, so heavily influenced by providers’ behaviour,
emerged as the major theme dictating patient–provider trust in all
four health centres. Three major factors emerged in relation to this
inter-personal trust (Table 3). The first was health workers’ per-
ceived lack of respect for patients or clients. Although some patients
did report positive experiences, examples of disrespectful behaviour
by health workers were reported by a number of patients in all
sites.3 Disrespect was most frequently linked to experiences of ver-
bal abuse or the perception that health workers’ simply didn’t care
about patients.
Nurses are very harsh with patients. Sometimes they shout at us.
OPD Patient, PHC4.
Yes, the nurse should be kind. They should know that they are
dealing with people who are sick. ART Patient, PHC1.
I sometimes feel like us patients are not respected here at the
clinic. MCH Client, HC2.
Linked to, but distinct from, perceptions of disrespect, the se-
cond theme patients reported on was the lack of professional ac-
countability for basic standards, particularly in relation to health
workers’ timeliness.
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The nurse is always chatting with her friends, just looking at her
phone; OPD Patient, PHC1,
The health workers at this clinic are lazy and very relaxed. They
take up too much time before attending to us. HIV Patient, PHC3.
In PHC1, PHC3 and PHC4, HIV patients frequently cited
misplacement or loss of medical files as evidence of providers’
lack of commitment or professionalism, implying in their descrip-
tions, their own inability to hold providers to account for such
issues.
The health workers at this clinic are very slow and those involved
with files keep losing them. They have lost my file this time, and
it is not the first time. I know I won’t be attended to today; HIV
Patient, PHC4.
Lack of professionalism was also indicated in patients’ com-
plaints about providers’ favouritism towards friends and family or
their willingness to accept informal fees.
The clinic works very well if you know someone because you go
straight to that person. Some patients give staff money. Some
they have an affair, so they can save money. Either way, [such
patients] will be attended to fast when they come to the clinic.
But no one [from the Ministry] is checking on [this problem];
HIV Patient, PHC4.
A third theme relating to patients’ inter-personal trust in pro-
viders was that of insufficient and poorly communicated informa-
tion. In the urban facilities especially, a number of patients
complained that health-care workers spent too little time with them
individually to be able to provide personalized care.
In the doctor’s room, he didn’t explain why I was going to the
lab. He just said ‘go to the lab’; OPD Patient, PHC1.
Yes a lot of people need information of what is happening to this
clinic and in the community and on ART is. Because we don’t
know. OPD Patient, PHC3.
Notably, and as illustrated by the quotes later, patients who per-
ceived providers to be disrespectful or lackadaisical also more often
conflated these concerns with other, more generalized service ineffi-
ciencies not linked to provider orientation, such as mandated health
facility opening hours, the environmental conditions of the facility
or drug stock-outs.
The [work] culture here is not good. Also [healthcare workers]
should be working twenty-four hours shifts so there is always
someone available. HIV Patient, PHC1.
The health workers should stop reporting for work late and we
need more toilets. OPD Patient, PHC2.
Influence of patient–provider trust on service quality
and responsiveness The effect of weak inter-personal relations and poor patient–
provider trust on service quality and responsiveness were profound.
Lack of confidence in provider empathy and anticipation of poor
service undermined patients’ tolerance of other more generalized or
structural health system constraints. Poor tolerance of health system
constraints in turn contributed to a range of patient responses (both
observed and reported) most commonly including attempts to skip
long queues (with or without informal fee payment—see Box 1) and
verbal arguments with providers (of varying degrees of intensity). In
more extreme cases (PHC3) patients were observed initiating phys-
ical shoving matches in an effort to establish an advantageous pos-
ition outside screening rooms or even physically blocking clinical
officers who were trying to leave at the end of their shifts.
A critical consequence of such actions was to contribute to pro-
viders’ own sense that clients were ill-educated or ill-mannered and
lacked understanding of the multiple pressures that they were
experiencing:
Patients are always complaining and lying about when they
arrived to try to make you go faster. Clinical Officer, PHC3.
The patient will not understand, they will look at you like you
don’t want to execute your services, they will look at you like
you are not even there, like you don’t care. But the [problem is
that] you don’t have [the equipment] to use. Nurse, PHC1.
Discussion
Although one of the most basic units of a health system, PHCs are
far more than just mechanisms of service delivery. Encompassing
Box 1. An example of a patient’s response to long
waiting times
‘Here you have to be clever. I show [the Peer Educator]
my plastic bag and then I leave the bag on the bench
and pretend to leave. Inside the bag, I put 5 000 kwacha
[$1.00USD]. So when [the Peer Educator] opens it he
takes that 5 000, he goes to the pharmacy and collects
my drugs and puts them inside the bag. Then he comes
with my bag to find me outside the shelter. He is going
to say: ‘Is this your bag?’ I will say: ‘Yes. Thank you! It
didn’t get lost. It’s my bag. I just want to go now.’ So, as
long as you have money, you go home early.’ HIV
Patient, PHC3.
Table 3. Factors influencing patient–provider trust in four Zambian health centres
Patient–provider trust
Sub-category Dimension of trust of mistrust Themes arising from data Hardware–software factors
Inter-personal trust Honesty
Fairness
Communication
Lack of provider respect
Lack of professionalism
Weak communication/transparency
of HCW actions
Under-staffing
Information asymmetries
Lack of opportunities to ‘voice’ concerns
Lack of mechanisms of social accountability
Institutional trust Competence
System trust
HCW’s formal qualifications
HCW’s role within facility
Availability of drugs/equip.
Power asymmetries
Tacit knowledge
HCW, health care worker; MOH, Ministry of Health
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a range of human actors, PHCs are complex, adaptive and social
systems in their own right (Sheikh et al. 2011; Topp et al. 2014).
Recognizing that human decisions, actions and relationships are at
the core of such systems, this study aimed to investigate the rele-
vance of the concepts of workplace and patient provider trust to
the Zambian setting and how factors influencing the production
of these different types of trust might shape service quality and re-
sponsiveness of PHCs. Contributing to a nascent body of
literature in this area, our findings (summarized in Figure 2) both
confirm the relevance of the concepts of workplace and patient–
provider trust and highlight the way interactions between these
types of trust are influencing service delivery through various
pathways.
Overall, findings from this study demonstrated low levels of
both workplace and patient–provider trust. Consistent with Gilson
et al.’s (2005) typology we found weak workplace trust was vari-
ously linked to providers’ weak trust in their government employer,
their health centre in-charges and their work colleagues. Drawing
on the Mechanisms of Effect framework (Topp et al. 2014) an im-
portant contribution of this work is to demonstrate more explicitly
how production of these various forms of trust was influenced by
interactions between material (hardware) and relational (software)
factors in the health centre setting.
In relation to workplace trust, for instance, interview and obser-
vational data demonstrated that long-term experiences of overwork
in frequently substandard work conditions damaged providers’ trust
in the government as either a respectful employer or one capable of
providing the basic resources needed to ensure basic service quality.
Providers’ lack of confidence in the government to establish the ma-
terial conditions necessary to work was inter-mingled with ongoing
frustrations related to remuneration. Matching findings from studies
elsewhere (Fox 1974; Pfeffer and Veiga 1999; Gilson et al. 2005a)
the data presented here suggest these factors combined had a power-
ful influence Zambian providers’ workplace motivation and patient
orientation.
Frustrations with material work conditions also formed an im-
portant backdrop for providers’ low levels of trust in supervisors
and colleagues. Across all four clinics, disappointment at being over-
looked for the limited professional development opportunities (e.g.
training or workshops) fed some providers’ perception that selection
decisions were driven by favouritism. Combined with in-charges’
generally weak communication or information-dissemination skills,
Figure 2. Interactions between weak workplace and patient–provider trust impact on service quality and responsiveness
Health Policy and Planning, 2016, Vol. 31, No. 2 201
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these perceptions fuelled more general suspicions of supervisor bias.
An overall sense of being treated unfairly both by their government
employer and supervisors, in turn, influenced providers’ trust in
their colleagues by fuelling concerns that other health workers were
somehow less accountable or obtaining unfair personal or profes-
sional advantage. Interestingly, in the smaller rural facility PHC2,
which, by necessity had a much flatter administrative hierarchy and
inter-professional task-shifting, findings suggested a greater degree
of trust amongst colleagues. Such findings align with existing evi-
dence that suggested that trust in colleagues is more likely to evolve
in more democratic institutional settings (Dirks 1999; Pearce et al.
2000; Gould-Williams 2003)
As summarized in Figure 1, providers’ weak workplace trust was
found to be strongly linked to a normative work culture that enabled
frequent blame-shifting and that rationalized negative attitudes to-
wards, and abuse of, patients. Such responses have been noted in
other settings (Brockner and Wiesenfeld 1996; Lewicki and Bunker
1996) and these behaviours formed the basis for weak inter-personal
trust between providers and patients, undermining patients’ confi-
dence in health workers’ service values or empathy.
An inverse pattern vis-à-vis trust in lay providers was demon-
strated, however, with patients’ initially weak institutional trust
often outweighed by the growth of inter-personal trust over time,
based on repeated experiences of respectful and personalized care.
As has been found in other health-care settings, therefore, we found
patient–provider trust to be simultaneously influenced by affective
judgements about providers’ sincerity, empathy and fairness, as well
as patients’ cognitive judgements about clinical competency
(Giddens 1990; Wuthnow 2004).
As noted in the literature, the development of impersonal trust in
settings involving a large number of interactions between relative
strangers are reliant, to a degree, on institutions and mechanisms of
accountability, such as rules, laws, norms and customs (Gilbert
2005; Gilson et al. 2005a). Findings from this study, however, dem-
onstrated that both patients and providers lacked confidence in the
rules, norms and institutions that should have guaranteed (in the
case of providers) a productive work environment and (in the case
of patients) responsive services.
Building on previously published work demonstrating endemic
weaknesses in mechanisms of both administrative and social ac-
countability in Zambian PHCs (Topp et al. 2014), the current study
thus makes an important contribution by providing meaningful evi-
dence of the way weak mechanisms of administrative and social ac-
countability interact with structural determinants (particularly
chronic resource shortages) to undermine workplace and patient–
provider trust in frontline Zambian health facilities. Providers’ lack
of confidence in the accountability of both their supervisors and
peers contributed to perceptions of being both professionally under-
valued and personally disadvantaged by arbitrary decision making
or unevenly applied standards. Many providers described their con-
cern with whether, and how, others might be gaining a financial or
professional advantage and the negative flow-on effects these suspi-
cions had in terms of teamwork, attention to medical and ethical
standards and patient-oriented care. At the same time, patients
lacked confidence in providers to deliver on their expectations.
Without the means to enforce these standards, patients often re-
sorted to small-scale bribes or queue skipping in an attempt to get
more timely or more personalized care. These actions exacerbated
patient–patient and staff–patient tensions, further undermining ser-
vice quality and responsiveness. The resulting negative feedback
loops and their impact on service quality and responsiveness are cap-
tured in Figure 2.
Study limitations and methodological considerations
This study’s conceptual framework and methodological approach
place a strong emphasis on the importance of context-specificity.
Since every context, by definition, is unique, it could be argued that
the findings presented here are specific to the experience of the four
health centres. To the extent possible, however, we have maintained
a distinction between the context specific analysis that addressed the
study’s ‘how’ and ‘why’ questions on the one hand, and theoretical
insights related to health system performance more generally. We
acknowledge that the research team’s disciplinary and professional
background (including significant prior experience working in
Zambian health centres) represent a potential source of bias that
may have predisposed the team to understand and analyse certain
issues in certain ways. Nonetheless, such experience could also be
seen as an advantage, providing a deeper understanding of the social
and institutional context in which both patients’ and providers are
operating and the paradoxical nature of their actions, decisions and
relationships.
Conclusion
Although more and deeper work is needed to understand how to de-
velop both macro- and micro-level institutions that ‘demonstrate the
norms of truthfulness, solidarity and fairness’ (Gilson 2003), our
findings do flag some important points. First, providers’ orientation
and behaviour towards patients is a critical ‘fulcrum’ on which the
production of trust in frontline health services balances. As our find-
ings illustrate, however, providers’ orientation is the product of mul-
tiple and intersecting factors, and disrespectful or abusive
behaviours are unlikely to be fixed by any single intervention,
particularly training (Gilson 2005). Two potential entry points for
tackling the sort of negative work culture described earlier might in-
clude investment in improved workplace conditions (system hard-
ware) as well as strengthened frontline leadership capacity (system
software). Recent work by several southern African consortia recog-
nizes and has already begun to act in the latter, complex leadership
domain (Gilson 2013; Mirzoev et al. 2014). In the long term, how-
ever, more and further-reaching structural reforms relating to
human resource for health management systems, including supervi-
sion, appraisal, disciplinary and reward mechanisms are likely to be
necessary.
This study highlights the importance of trust as a mechanism
influencing both health care workers’ performance and patient re-
sponses, and its role in shaping health centre relationships central to
generative and protective service delivery. Application of the
Mechanisms of Effect framework with its emphasis on hardware–
software interactions drew attention to the way both material and
relational health system components influenced the production of
these different types of trust and with what effects on health centre
performance.
Our findings contribute to a small but growing body of
evidence demonstrating how and why breakdowns in trust have
occurred in public sector services in Zambia and demonstrate the
critical consequences of these breakdowns on service quality
and responsiveness. The study flags the importance of strengthening
investment 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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Acknowledgements
The authors thank all the participants involved in the research, particularly
the staff and patients of the four health facilities, and the respective district of-
ficials. S.T. thanks Prof. Jim Black and Dr. Martha Morrow for their support
and advice in the process of carrying out this study.
Funding
This work was supported by an Australian Post-Graduate Award (APA) for
Doctoral Research, through the University of Melbourne, Australia.
Ethical Clearance
The study received ethical clearance from the Human Research Ethics
Committee of the University of Melbourne (Ref 1035194) and the University
of Zambia Biomedical Research Ethics Committee (Ref 004-03-011).
Conflict of interest statement. None declared.
Notes 1 Since one of the study’s overall goals was to assess the impact of
introducing HIV services into primary health centres, this was a
necessary criterion. 2 Frustrations with ‘duty creep’ were common but not universal
amongst those interviewed with examples given by individuals
in Health Centres 1, 2 and 4 describing their enthusiasm for tak-
ing on greater clinical responsibilities (We have few clinical offi-
cers so l just have to beef up [screening] now and then. I like it.
These other professionals they are specific but nursing is so dy-
namic) and in one exceptional case (Clinic 4) a newly graduated
nurse practitioner with the skills to manage and screen stable
HIV patients paradoxically complained that she was unable to
utilize her new skills as she continued to be rostered for just
‘basic nursing duties.’ 3 Although complaints about provider disrespect and abuse were
recorded from patients in all departments, comparatively more
patients from the outpatient department complained compared
with the maternal and child health, HIV or tuberculosis
departments.
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