Trust and reliability in public health systems

Trust and reliability in public health systems

Trust and reliability in public health systems- Today Current Affairs

Public trust is the most crucial value in public health like immunisation campaigns and other large-scale public health programmes. Closely related but also very crucial is the trust necessary for effective medical practice. The close relationship between the two is because the public at large links health and well-being to hospitals and medical care even though there is a reciprocal relationship between public trust in health systems and people’s well-being and social order. Its unique nature in medicine owes from its inherent chara­cter of information asymmetry between the doctor, the expert, and the patient, non-expert.

Medical interactions in the last instance are about life and death decisions and become more complex in the case of newer epidemics like COVID-19, as treatment modalities and its outcomes are determined not only by the science of medicine but also by the institutional context where it is practiced. 

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Fear of Treatment: The Hindu Analysis

COVID-19 poses multiple dimensions of fear arising from the risk of getting infected, its mode of spread and possible severity of the disease, and more importantly, the possibility that it can become fatal. Of all these, the last one is linked directly to the treatment options available and the challenges in accessing them. The immediate concerns for a COVID-19 positive patient regarding the treatment are: What kind of quality can one expect in a public hospital? Is that sufficient and safe enough to get rid of the illness? What will be the cost incurred in the private sector? How much one would need to spend from one’s pocket? These are the thoughts that people grappled with during the first and second wave of the pandemic amid grossly inadequate healthcare infrastructure across India.

Private Sector : The Hindu Analysis

Privatization of healthcare has been a consistent policy of all the national and state governments in India, raising the bar high for the underfunded public sector. The dominance of “patient-clients­” redefined the image of hospitals and quality parameters of the private sector. Additionally, the purchasing power of pati­ents and the business in healthcare determine the expectation of the care provided. The commercialisation of medical practice attains “normalcy” wherein patients always tend to negotiate the type and cost of services rendered in a private hospital. In reality, little can the patient negotiate on the core of the medical practice that lies within the terrain of the expert—the practicing doctor—and what really gets negotiated at the end is the type of room they avail, the discount in any of the charges, and other peripheral services.

The power of medicine and its know­ledge consistently pose barriers for the patient-client to negotiate on the core of medical practice. The middle class and the rich, who constitute the patient-client have increased their skepticism even towards the core of medical practice. 

Public Sector : The Hindu Analysis

The middle class has been moving away from utilizing the public sector hospitals for more than two decades (Qadeer 2000). The poor utilizing the public sector with an overcrowded environment and grossly inadequate infrastructure has created an impression that the public sector is bound to be “inefficient” with little to expect from its services. The mostly poor beneficiaries are habituated with sharing beds with other pati­ents, with relatives spending longer time on the floors of the wards, and with poorly maintained water supply, toilet facilities, and other services. This has created an impression among those who use the public sector healthcare services that nobody is really bothered. The commitment of health professionals, especially medical doctors, are always looked upon with faith and appreciation by the patients 

. Each patient’s “life” is always considered at the mercy of the professionals’ goodwill. Commitment of health professionals are worshiped by patients and is trusted upon more than the institutional infrastructure. If anything goes wrong in treatment, it is always considered as a lack of commitment and oversight of the health professionals. Rarely does the patient focus on the systemic failures that operate beyond the competency of health professionals, which can go wrong anytime in ailing public hospitals. 

Vaccine Hesitancy : The Hindu Analysis

The second aspect where trust in public health matters more is in the context of vaccine hesitancy, which is identified by the World Health Organization (WHO 2019) as one of the 10 major public health threats to global health in this century. The relevance and intensity became more obvious in the current context of the COVID-19 pandemic in India and also across several parts of the world.

In India, there are diverse efforts by the government and civil society agencies to tackle this. Some of the states, ­using institutional power, make vaccination mandatory for a range of government employees to continue their work. This was the case when vaccination was made mandatory for most healthcare workers, as a high-risk group, in the initial period. Several corporate offices ext­ended this policy to make it compulsory by facilitating vaccination drives to its employees. Yet another effort by the state includes imposing travel restrictions across states and even nations for those who are not vaccinated. There were also incentive-based approaches, wherein freebies are offered for those vaccinated in shopping malls, other recreation sites, and even tourist sites. 

Health education is undoubtedly one of the most important and accepted public health interventions proposed for health behavior change in a population and was perceived as having the potential to build trust. The underlying idea is to provide information about the event, and the public is persuaded to follow positive behavior through education and effective communication.

Scientific Temper and Trust Society : The Hindu Analysis

Let us further examine the problem of vaccine hesitancy. Some argue vaccine hesitancy is due to an increase in irrational and superstitious beliefs among people. The only way to address this problem is by increasing rationality and scientific thinking.  More and more evidence on vaccine hesitancy points to the role of social media and other sources that distort the message about events, which then creates confusion among the public. The reality is much more complex. There is expert know­ledge about medicine and vaccines that cannot be expected to reach the common public as an everyday knowledge and related rationality. For inst­ance, what is the knowledge that society tries to inculcate among the public on vaccines? Is it about the dosage? Or is it about the vaccine and its efficacy in preventing hospitalization and death in the case of COVID-19? Or is it about the div­erse variants and the type of vaccine found effective against each variant? If we go one step ahead, it is essential to know your audience if we are to explain the science of antigen and antibody reac­tions. This information has many technical details involved even to make proper sense to an educated crowd from a non-scientific background.

Eventually, the message boils down to a fundamental “belief” that vaccines can help prevent people from getting COVID-19. Is this knowledge-based understanding, or is it trust towards those who say it? Trust towards the authority and institutions who propagate the message becomes crucial and not the scientific content that follows it. Studies have shown that the officer who provides the message and the authority’s sanctity matter more to the public than the content per se (Avery 2010; Cummings 2014). This logic is one of the reasons why religious leaders and local leaders were asked to persuade their own religious groups to adopt vaccines, family planning, and other public health programmes.

Another aspect that interferes with public understanding is the trust heuristic and the informal fallacy (Cummings 2014). Several events that are witnessed by the public can be a counter-narrative to the larger scientific knowledge. For instance, vaccines are understood to prevent occurrence itself for a range of diseases. However, in the context of COVID-19, it is possible that those vaccinated can get infected—a new “normal” in the knowledge about vaccination. 

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The Way Forward

Let us examine the factors that build a “trust society,” as it is a dynamic process and not an endpoint. One can understand this across macro, meso, and micro levels. The larger political and government machinery at the macro level and its egalitarian, progressive, and inclusive policies can build trust. In other words, it is the sense of confidence guaranteed by the state to its citizens at large. At the meso level, trust is built based on the routine engagement of the citizen with the existing institutions and people in their everyday life. These include people’s experiences with their primary institutions like ration shops, transportation, anganwadi centers, and more importantly, their healthcare faci­lities that they can access. 

There has been a gross failure of the health services to build the trust necessary for people to seek healthcare during a crisis. The erosion of trust towards institutions of medical practice has been in its making from the time we followed the policies of privatization of healthcare and has attained its peak during a crisis like COVID-19. Any profession and its institutions are valued based on its ability to respond during a crisis, and it is time for policymakers to recognise the crucial role of hospitals as an essential social institution for the very existence of a society whose control cannot be left to the market forces. This trust-building is a process based on past experiences built through engagement with their institutions and service providers over a longer period. It cannot sustain when it is socially engineered as done in incentive-based approaches or the use of religious leaders as and when needed as seen in public health programmes. 


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