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

Topp, Stephanie M., and Chipukuma, Julien (2016) 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. BMJ Global Health, 1 (4). e000179. pp. 1-13.

PDF (Published Version) - Published Version
Available under License Creative Commons Attribution Non-commercial.

Download (1MB) | Preview
View at Publisher Website:


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, 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.

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.

Item ID: 46736
Item Type: Article (Research - C1)
ISSN: 2059-7908
Keywords: health systems, trust, HIV services, scale-up, health system strengthening
Additional Information:

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial.

Date Deposited: 15 Jan 2017 22:54
FoR Codes: 42 HEALTH SCIENCES > 4203 Health services and systems > 420399 Health services and systems not elsewhere classified @ 50%
44 HUMAN SOCIETY > 4407 Policy and administration > 440708 Public administration @ 10%
44 HUMAN SOCIETY > 4410 Sociology > 441001 Applied sociology, program evaluation and social impact assessment @ 40%
SEO Codes: 92 HEALTH > 9202 Health and Support Services > 920207 Health Policy Evaluation @ 30%
92 HEALTH > 9202 Health and Support Services > 920299 Health and Support Services not elsewhere classified @ 50%
94 LAW, POLITICS AND COMMUNITY SERVICES > 9403 International Relations > 940302 International Aid and Development @ 20%
Downloads: Total: 920
Last 12 Months: 11
More Statistics

Actions (Repository Staff Only)

Item Control Page Item Control Page