How did rapid scale-up of HIV services impact on workplace and interpersonal trust in Zambian primary health centres: A case-based health systems analysis

Background: In sub-Saharan Africa, large amounts of funding continue to be directed towards HIV-specific care and treatment, often with claims of ‘health system strengthening’ effect. Such claims rarely account for the impact on human relationships and decisions that are core to functional health systems. This research examined how establishment of externally funded HIV services influenced trusting relationships in Zambian health centres. Methods: An in-depth, multicase study included four health centres selected for urban, peri-urban and rural characteristics. Case data included healthcare worker (HCW) interviews (60); patient interviews (180); direct observation of facility operations (2 weeks/ centre) and key informant interviews (14) which were recorded and transcribed verbatim. Thematic analysis adopted inductive and deductive coding guided by a framework incorporating concepts of workplace trust, patient-provider trust, intrinsic and extrinsic motivation. Results: HIV service scale-up impacted trust in positive and negative ways. Investment in HIV-specific infrastructure, supplies and quality assurance mechanisms strengthened workplace trust, HCW motivation and patient-provider trust in HIV departments in the short-term. In the health centres more broadly and over time, however, nongovernmental organisation-led investment and support of HIV departments reinforced HCW’s perceptions of the government as uninterested or unable to provide a quality work environment. Exacerbating existing perceptions of systemic workplace inequity and nepotism, uneven distribution of personal and professional opportunities related to HIV service establishment contributed to interdepartmental antagonism and reinforced workplace practices designed to protect individual HCW’s interests. Conclusions: Findings illustrate long-term negative effects of the vertical HIV resourcing and support structures which failed to address and sometimes exacerbated HCW (dis)trust with their own government and supervisors. The short-term and long-term effects of weakened workplace trust on HCWs’ motivation and performance signal the importance of understanding how such relationships play a role in generating virtuous or perverse cycles of actor interactions, with implications for service outcomes.

This study was set in Zambian PHCs providing HIV and a variety of routine outpatient and maternal and child health services. PHCs make up the majority (79%) of Zambia’s health facilities, with ∼29% of these located in urban areas. Nominally, urban PHCs serve a catchment of 30 000 to 50 000 people and rural PHCs serve a population of up to 10 00044 although actual catchment populations are often larger. PHCs along with first level hospitals are administrated by District Health Offices, while Provincial Health Offices and central Ministry of Health (MOH) offices manage secondary and tertiary hospital operations, respectively. The typical administrative structure for PHCs includes an overall health centre manager (‘in-charge’) deputised by various departmental managers responsible for outpatient, tuberculosis (TB), maternal and child health (MCH) and ‘antiretroviral therapy (ART) clinic’ services. Following the 2003 announcement of a policy promising free and universal access to ART and subsequent financial support from GFATM and PEPFAR (among others), Zambia rapidly introduced ART clinics at the PHC level with the assistance of various non-government ‘implementing partners’. At the time of writing, Zambia had one of the world’s largest HIV-treatment programmes with more than 600 000 HIV-infected individuals enrolled in care. The overall aim of this study was to examine whether and how the scale-up of HIV services impacted on workplace and patient–provider trust in four Zambian PHCs. The methods for the larger project of which this study formed one part have been described in detail elsewhere.36 Of relevance to this study a multicase design was adopted45 with four PHCs each representing a case unit. Health centres were purposively chosen from two districts within the same province and selection was based on established (>36 months) HIV care and treatment service and a catchment population based on either a large urban facility (>100 000 population), small urban facility (40 000–70 000), peri-urban facility (<40 000) or rural facility (<30 000), respectively. A list of all facilities that fitted the criteria was initially developed and case selection conducted in collaboration with District Medical Officers and local colleagues simultaneously accounting for access and logistical issues. Final selection was subject to the informed consent of the manager of each centre. Data were collected between June and December 2011. Data collection methods included document review, in-depth interviews with a proportionate sample of healthcare workers from all health centre departments (n=60); structured observations and semistructured interviews (conducted postconsultation/observation) with a quasi-random sample of patients (n=180); 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 (eg, medical history, physical examination and blood draw) and the type of information exchanged between health workers and patients during routine screening visits in the outpatient, 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 interactions. Key informant interviews with government and non-government officials (n=14) with specific knowledge or experience in front line supervision were additionally conducted. Question guides were designed to elicit detailed descriptions of interactions among and between staff and patients to provide insight into whether and why the introduction and scale-up of HIV service delivery influenced trust in health centre relationships. Prior experience of conducting interviews in Zambian health centres46 47 demonstrated that when asked direct questions about interpersonal interactions, patients and providers often provided undifferentiated and affirming descriptions despite observations suggesting more complex of relationships. Owing to this risk of social desirability bias, question guides did not ask directly about trust.48 Rather, following the conceptual framework outlined above, issues explored under the rubric of workplace trust included contrasting health worker expectations and perceptions of support from their employer or quasi-employer (eg, non-governmental organisation (NGO) implementing partner); expectations and perceptions of line managers and collegiality—including willingness to rely or depend on other health workers under different conditions. Issues explored under the rubric of interpersonal trust included HIV and non-HIV patients' expressions of faith in health workers' service skills and service orientation; confidence that health workers in different departments were adequately skilled and hopes, expectations and experiences of receiving timely and respectful care. Responses were triangulated with direct observations to provide a better understanding of the way HIV services and associated support activities influenced different aspects of workplace and patient–provider trust. The primary investigator conducted all the health worker interviews in English. Patient interviews were conducted by one of 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 observations or interviews. The study received ethical clearance from the Human Research Ethics Committee of the Nossal Institute, University of Melbourne, and the University of Zambia Biomedical Research Ethics Committee. Analysis was carried out in three phases. Phase I was conducted concurrently with data collection, as collated notes and summaries of evidence were generated for each health centre and transcribed interviews imported into NVivo V.8 QSR for electronic coding. In phase II, data were organised to produce a case description for each health centre. Qualitative and observational data were synthesised and compared in order to develop as comprehensive a picture as possible of the impact of HIV service scale-up on trust at each site with preliminary case descriptions disseminated to the health-centre managers and District Medical Officers to garner feedback. Phase III focused on cross case comparisons using deductive and inductive analysis. Initial deductive analysis was guided by codes developed from the conceptual framework including: system hardware (financing, human resourcing, drug supplies); system software (leadership, workplace norms, patient expectations); workplace trust (employer, supervisor, colleagues) and patient–provider trust (interpersonal, institutional). Coded text and its (anonymised) source were collated in a word document and printed to enable synthesis of major findings. Theoretically, generated codes were supplemented with inductive codes, and commonalities identified across the four cases.

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• Dima Health