Tibandebage Paula, Mackintosh Maureen
The Open University, Faculty of Social Sciences, Walton Hall, Milton, Keynes MK7 6AA, UK.
Soc Sci Med. 2005 Oct;61(7):1385-95. doi: 10.1016/j.socscimed.2004.11.072.
Effective health care is a relational activity, that is, it requires social relationships of trust and mutual understanding between providers and those needing and seeking care. The breakdown of these relationships is therefore impoverishing, cutting people off from a basic human capability, that of accessing of decent health care in time of need. In Tanzania as in much of Africa, health care relationships are generally also market transactions requiring out-of-pocket payment. This paper analyses the active constitution and destruction of trust within Tanzanian health care transactions, demonstrating systematic patterns both of exclusion and abuse and also of inclusion and merited trust. We triangulate evidence on charges paid and payment methods with perceptions of the trustworthiness of providers and with the socio-economic status of patients and household interviewees, distinguishing calculative, value based and personalised forms of trust. We draw on this interpretative analysis to argue that policy can support the construction of decent inclusive health care by constraining perverse market incentives that users understand to be a source of merited distrust; by assisting reputation-building and enlarging professional, managerial and public scrutiny; and by reinforcing value-based sources of trust.
有效的医疗保健是一种关系性活动，也就是说，它需要提供者与需要并寻求医疗服务者之间建立起信任和相互理解的社会关系。因此，这些关系的破裂会使人变得匮乏，使人们无法获得一种基本的人类能力，即在需要时获得体面医疗保健的能力。与非洲大部分地区一样，在坦桑尼亚，医疗保健关系通常也是需要自掏腰包支付费用的市场交易。本文分析了坦桑尼亚医疗保健交易中信任的积极构建与破坏，揭示了排斥与滥用以及包容与应得信任的系统性模式。我们将支付费用和支付方式的证据与对提供者可信度的认知以及患者和家庭受访者的社会经济地位进行三角测量，区分出基于算计、基于价值和个性化的信任形式。我们利用这一解释性分析认为，政策可以通过抑制用户认为是应得不信任根源的不正当市场激励措施；通过协助建立声誉并扩大专业、管理和公众监督；以及通过强化基于价值的信任来源，来支持构建体面包容的医疗保健体系。
