Trust in health care: theoretical perspectives and research needs.
OBJECTIVE
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.


METHODS
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.


RESULTS
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.


CONCLUSIONS
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.


CONCLUSIONS
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.
Gilson
Lucy
L
Centre for Health Policy, University of Witwatersrand, Johannesburg, South Africa. lucy.gilson@nhls.ac.za
D003906:Developing Countries; D006801:Humans; D008962:Models, Theoretical; D010817:Physician-Patient Relations; D011369:Professional-Patient Relations; D012106:Research; D035502:Trust