Topp Stephanie M, Chipukuma Julien M
College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia.
Nossal Institute for Global Health, University of Melbourne, Melbourne, Victoria, Australia.
BMJ Glob Health. 2016 Dec 16;1(4):e000179. doi: 10.1136/bmjgh-2016-000179. eCollection 2016.
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.
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.
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, non-governmental 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.
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.
在撒哈拉以南非洲地区，大量资金持续投入到针对艾滋病病毒（HIV）的护理和治疗中，且往往宣称具有“加强卫生系统”的效果。此类宣称很少考虑对人际关系以及功能健全的卫生系统核心决策的影响。本研究调查了外部资助的HIV服务机构的设立如何影响赞比亚各卫生中心的信任关系。
一项深入的多案例研究选取了四个分别具有城市、城郊和农村特征的卫生中心。案例数据包括对医护人员（HCW）的访谈（60次）；患者访谈（180次）；对机构运营的直接观察（每个中心为期2周）以及关键信息提供者访谈（14次），所有访谈均进行记录并逐字转录。主题分析采用归纳和演绎编码，以一个包含工作场所信任、医患信任、内在和外在动机等概念的框架为指导。
HIV服务的扩大在积极和消极方面都对信任产生了影响。对HIV特定基础设施、物资和质量保证机制的投资在短期内增强了工作场所信任、医护人员的积极性以及HIV科室中医患之间的信任。然而，从更广泛的范围以及长期来看，非政府组织主导的对HIV科室的投资和支持强化了医护人员认为政府对提供优质工作环境不感兴趣或无能为力的看法。与HIV服务机构设立相关的个人和职业机会分配不均加剧了现有的系统性工作场所不公平和裙带关系观念，导致部门间的对抗，并强化了旨在保护医护人员个人利益的工作场所行为。
研究结果表明了垂直的HIV资源配置和支持结构的长期负面影响，这些结构未能解决甚至有时加剧了医护人员对其政府和上级的不信任。工作场所信任减弱对医护人员积极性和绩效的短期和长期影响表明，理解此类关系如何在产生良性或恶性循环的行为者互动中发挥作用具有重要意义，这对服务结果也有影响。
