Finding and Forging Trust in Health System Strengthening

Published July 01, 2015 under Voices of DGHI

Bass team with Afya Research staff, Kibera Slum, Nairobi, Kenya

Bass team with Afya Research staff, Kibera Slum, Nairobi, Kenya

By Joe Egger, DGHI research scholar

Like our own United States healthcare system, Kenya’s system is fractured and provides unequal access and quality of care to its population. On our recent trip to East Africa, however, we witnessed a region full of smart, dedicated and entrepreneurial people involved in innovative activities to create a stronger and better healthcare system.

Our Bass team met with people from non-governmental organizations, faith-based organizations, small private clinics, large hospitals, business consultants, academics, community members and patients. Our goal in these discussions was to learn about promising new approaches to providing healthcare, and the challenges that private healthcare enterprises face in scaling the impact of their work in resource-limited settings like rural Rwanda and urban Nairobi. In these discussions, the concept of “trust” repeatedly came up.  

Trust may be a somewhat tired and trite idea in relation to healthcare delivery. We know that clinical providers everywhere need to earn the trust of their patients and their patients’ families. Nonetheless, the word trust came up over and over in our conversations, in relation to clinical delivery, but also in relation to the many business and management components necessary to build a successful healthcare enterprise.

In Rwanda, we toured a district hospital that was opening its new maternity wing, the result of a strong public-private partnership between an NGO and the Ministry of Health (MOH). This maternity wing represented phase 4 of the hospital’s development. The first phase, started almost a decade ago, had been funded entirely by the NGO, and phases 2 and 3 each saw declines in funding support from the NGO, and increases by the MOH. Phase 4, we learned, was funded entirely by the MOH, with technical support provided by the NGO. We asked our hosts why the MOH had not initially put up funds for the first phase and they told us that the NGO needed to earn the MOH’s trust before the government felt comfortable in committing resources to the project. Both organizations are now strong, lasting partners, engaged in some of the most innovative, creative health system strengthening projects we have seen—all occurring in a district in Rwanda that did not have a hospital ten years ago.

In Kenya, we found that creative health workforce staffing and development are critical components to building a successful healthcare enterprise. Many Kenyans who cannot afford access to the best private facilities are dubious of the care they will receive at most public clinics. This lack of trust has, in part, led to a situation today where over half of all health services in Kenya are provided by the private sector. However, trust in the private sector is not much better. Even in many private clinics there is a perceived inconsistency in the quality of care and availability of non-fraudulent medicines.

One chain of primary clinics we visited in Nairobi is trying to address this issue of patient trust by providing consistently high quality care at a low price, using a high volume/low cost model. They are doing this by working closely with their clinical officers (CO) to provide continuing medical education and evidence-based performance feedback to each provider. After a relatively short intervention, the organization has seen a dramatic increase in the adherence to international clinical quality guidelines by its COs. Senior staff from this organization told us that they believe the single biggest factor in improving adoption of the guidelines, and therein clinical quality, in their clinics has been building a culture of respect and trust between clinical and administrative staff. Building this trust through frequent one-on-one feedback sessions with COs allows the clinicians to feel comfortable in coming to senior staff when they have questions, and more relaxed and confident in performing their duties.

In Kenya, we also visited a faith-based hospital that provides some of the best inpatient and outpatient care in the country, all on very limited resources and a passionate, dedicated workforce. After touring the hospital, the staff took us to a beautiful new regional medical clinic it had opened in the Rift Valley. The maternity ward was completely empty. We asked why. The Kenyan government, they explained, had recently enacted legislation that made maternal and neonatal care covered under the national insurance plan and, therefore, free to patients. We wondered the extent to which this lack of communication, planning and transparency has compromised the trust between this FBO and the public sector. Perhaps the road to distrust is paved with good intentions …

On our last day, we visited a brothel in a slum outside of Nairobi. A local NGO has engaged sex workers to provide community outreach to encourage other sex workers and their clients to seek HIV testing and treatment at the local medical center. In one of the town’s many brothels, we talked with sex workers and members of the NGO about their relationship, and how they managed to make this unlikely partnership work in a resource-limited environment where prostitution was illegal. The NGO staff worked in the slum, they walked the streets, befriended its citizens and had clearly gained their trust. They saw the NGO staff as friends and colleagues, and they were improving the health of Kenyans together.

Health systems are fragile and consist of intricate, often tenuous social bonds between many different individuals and organizations. Trust between these links is critical for a strong system to survive and thrive.