Gilson Lucy
Centre for Health Policy, University of Witwatersrand, Johannesburg, South Africa.
J Health Organ Manag. 2006;20(5):359-75. doi: 10.1108/14777260610701768.
This paper presents some key theoretical issues about trust, and seeks to demonstrate their relevance to understanding of, and research on, health systems. Although drawing particularly on empirical evidence from low- and middle-income countries (LMICs), the paper aims to stimulate thinking across country settings.
DESIGN/METHODOLOGY/APPROACH: Drawing both on conceptual literature and relevant empirical research from LMICs, the paper presents an argument about the role of trust within key health system relationships and identifies future research needs.
Theoretical perspectives on four questions are first discussed: what is trust and can it be constructed? Why does it matter to health systems? On what is it based? What are the dangers of trust? The relevance of these theoretical perspectives is then considered in relation to: understanding the nature of health systems; issues of equity and justice in health care; and policy and managerial priorities. The identified research needs are investigation of: the role of trusting workplace relationships as a source of non-financial incentives; the influence of trust over the operation of different forms of citizen-health system engagement; approaches to training trustworthy public managers; and the institutional developments required to sustain trustworthy behaviour within health systems.
The policy and management actions needed to strengthen health systems within LMICs, and elsewhere, include: recruitment of health workers that have the attitudes and capacity for moral understanding and motivation; training curriculae that develop such motivation; and developing the institutions (e.g., communication and decision-making practices, payment mechanisms) that can sustain trusting relationships across a health system. It is also important to recognise that distrust in some relationships may act to guard against the abuse of power.
ORIGINALITY/VALUE: Although the notion of trust has become of increasing importance in health policy debates in high-income countries, it has received less attention in the context of LMICs. The papers adds to the very limited literature on trust in LMIC health systems and also opens new lines of thinking for those working in high income countries--particularly around the role of health systems in generating wider social value.
本文提出了一些关于信任的关键理论问题，并试图证明它们与理解卫生系统及卫生系统研究的相关性。尽管本文特别借鉴了低收入和中等收入国家（LMICs）的经验证据，但其目的是激发不同国家背景下的思考。
设计/方法/途径：本文借鉴了概念文献和来自低收入和中等收入国家的相关实证研究，提出了关于信任在关键卫生系统关系中的作用的论点，并确定了未来的研究需求。
首先讨论了关于四个问题的理论观点：什么是信任，信任能否被构建？为什么信任对卫生系统很重要？信任基于什么？信任有哪些风险？然后结合以下方面考虑这些理论观点的相关性：理解卫生系统的性质；医疗保健中的公平和正义问题；以及政策和管理重点。确定的研究需求包括：调查信任的工作场所关系作为非财务激励来源的作用；信任对不同形式的公民与卫生系统互动运作的影响；培养值得信赖的公共管理人员的方法；以及在卫生系统内维持值得信赖行为所需的制度发展。
在低收入和中等收入国家及其他地区加强卫生系统所需的政策和管理行动包括：招聘具有道德理解和动机态度及能力的卫生工作者；制定培养这种动机的培训课程；以及建立能够在整个卫生系统维持信任关系的机构（如沟通和决策实践、支付机制）。同样重要的是要认识到，某些关系中的不信任可能起到防范权力滥用的作用。
原创性/价值：尽管信任的概念在高收入国家的卫生政策辩论中变得越来越重要，但在低收入和中等收入国家的背景下受到的关注较少。本文增加了关于低收入和中等收入国家卫生系统中信任的非常有限的文献，也为高收入国家的工作人员开辟了新的思路——特别是围绕卫生系统在创造更广泛社会价值方面的作用。
