Trust and the development of health care as a social institution
Introduction
Health systems are inherently relational and so many of the most critical challenges for health systems are relationship problems. Poor staff attitudes towards patients can cause dissatisfaction with services, which even good technical care may not offset. Such attitudes may, in turn, result from de-motivating management practices and behaviours. International concern with the weak responsiveness of health systems towards its users, particularly in low income countries, reflects these sorts of problems (World Health Organisation, 2001). At the same time, concern about the broader relationship between health care and society is reflected in discussions about the decline of popular trust in health systems (Birungi, 1998; Davies, 1999; Mechanic, 2001; Segall, 2000; Tendler & Freedheim, 1994; Welsh & Pringle, 2001).
The dominant perspectives applied within health policy analysis, however, offer few insights into the nature and value of health system relationships. Epidemiological and biomedical frameworks are of limited assistance in understanding the internal dynamics of health systems, whilst the core behavioural assumption of traditional economic analysis, that human behaviour is primarily rational and calculative, is flawed. Critics suggest that this economic understanding of human behaviour and how it is shaped is inadequate (Kiser, 1999; Gregory, 1999) and, by inhibiting the expression of social solidarity, may have dangers for re-distribution and equity (Mackintosh, 1997; Melhado, 1998).
Yet outside the health sector, and across a range of disciplines, there has been an explosion of interest, conceptual discussion and policy debate concerning relationships, behaviour, and the factors that influence them. A central feature of these debates, particularly, but not only, in relation to social capital (Coleman, 1990; Putnam, 1993), is trust and its role in facilitating collective action, that is co-operation among people to achieve common goals. Economists, both within and outside the health sector, have also been reviewing their traditional behavioural assumptions and have re-emphasised the influence of values and institutions,1 including trust, over behaviour (e.g. Ben-Ner & Putterman, 1998; Le Grand, 1997; Sen, 1977; Wiseman, 1998).
Table 1 provides details of five different bodies of literature in which trust has recently been emphasised. Although they draw on a range of disciplinary perspectives, discussion of social capital is linked to four of these five sets of literature. The table also indicates the varying range of policy implications that have been derived from consideration of trust. As Misztal (1996, p. 95) suggests, trust “can be a silent background, sustaining the unproblematic, smooth running of cooperative relations. It can be a solution to the free-rider problem. It can help people to reconcile their own interests with those of others. It can provide political leaders with the necessary time to carry out reforms. It can provide friends or lovers a platform from which to negotiate their relations. But above all, trust, by keeping our mind open to all evidence, secures communication and dialogue”. Moreover, as an underlying concern of current public policy debates is that the existing bases of social cohesion have been eroded, the particular potency of trust comes from its role as “a symbolic carrier of lost values, acting as a counter to economic individualism in the market place, to hierarchy within organisations, and to the effects of fragmentation across contractualised relationships” (Newman, 1998, p. 51).
What do the debates on trust have to offer health policy analysis? This paper considers the question by considering the meaning, bases and outcomes of trust, and its relevance to health systems. Through an eclectic use of theoretical perspectives drawn from various disciplinary traditions and lines of policy debate, the paper seeks both to establish a conceptual basis for considering the relevance of trust to health systems and to demonstrate the diverse intellectual roots of its argument.
There are two main sections to the paper. The first presents a synthesis of theoretical perspectives on the notion of trust. Drawing on this discussion, the second then argues both that trust underpins the co-operation within health systems that is necessary to health production, and that a trust-based health system can make an important contribution to building value in society. Finally, five conclusions are drawn for an approach to health policy analysis that takes trust seriously.
Section snippets
What is trust and why does it matter?
Trust is a relational notion: it generally lies between—people, people and organisations, people and events. It may also be considered as self-trust, but this notion is not considered further in this paper.
The role of trust in key health system relationships
The production of health and health care requires co-production (Alford, 1993; Cahn, 1997) between patient and provider and co-operation among health system agents. Can trust facilitate these different levels of co-operation? To answer this question it is important to think through the role that inter-personal trust plays within any health system, as well as the way that inter-personal trust is shaped by the broader institutional setting. In both cases the expectations that underpin trusting
Conclusions
Overall, this paper argues that trust matters to health systems and trust-based health systems matter to society. People value health systems not only for the care they themselves receive in times of sickness but also for the contribution the systems make to the broader well-being of society. From this argument the paper also offers five specific pointers for health systems and policy analysis.
First, health systems comprise a complex web of relationships whose overall functioning and
Acknowledgements
I am most grateful for the support of a group of friends and colleagues who have thought with me about trust, as well as read and commented on this paper. They cannot, however, be held responsible for the final product. Thanks to Duane Blaauw, Annabel Bowden, Jane Goudge, Anne Mills, Gavin Mooney, Helen Schneider, Liz Walker, and Gill Walt. Lucy Gilson is a part-time member of the Health Economics and Financing Programme at the London School of Hygiene and Tropical Medicine, which receives
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