Better health services rest on building trust among healthcare workers

South Africa has a health workforce in crisis. Nic Bothma/EPA

A health system that communities experience as uncaring and unaccountable undermines and ultimately destroys trust in the health system. The most visible signs of a dysfunctional health system are the performance of its healthcare workers, specifically those working at the interface with communities. This includes nurses, doctors and community health workers.

Over time, South Africa has witnessed more and more negative media coverage depicting healthcare workers as uncaring. In some instances they have even been described as abusive. Unsurprisingly the country’s Health Minister Aaron Motsoaledi issued a severe warning to health professionals because “patients deserve compassionate nurses‚ not devils”.

Few would argue that poor and disrespectful care challenges efforts to rebuild a health system that equitably serves the health needs of all South Africans. But is Motsoaledi failing to recognise – and possibly ignoring – the underlying issues of a health system that is failing both its patients and healthcare workers?

In 1994 in South Africa, a promise was made to transform the health system into a well-resourced and functioning one. It would deliver quality, safe and effective health care and be responsive to communities and patients’ needs, particularly the most marginalised and vulnerable.

Remarkable progress has been made since then. Pro-equity policies and laws have been passed, a district health system has been put in place and resources have been reallocated. But the country’s health system is overwhelmed by persistent under-resourcing, drug shortages, insufficient and poor distribution of healthcare workers. This is particularly true in poor provinces especially outside cities and towns.

For healthcare workers, these perennial challenges combined with inadequate pay, poor working conditions and unsupportive supervision contributes to a work force that is demoralised and demotivated. The evidence shows that healthcare workers don’t believe that they work in caring and supportive environments. This results in them feeling extremely vulnerable. The consequence is poor performance, delivery of poor quality care and ineffective health services.

My study has built on this. And it explains why healthcare workers have lost trust that the system is acting in their best interests.

It’s evident that as a result of these challenges South Africa has a health workforce in crisis.

Trust and motivation

Employees who are motivated perform better. They also stay. The same holds for healthcare workers. What motivates healthcare workers to perform better and ultimately provide respectful and effective patient care?

Research from high-income and now increasingly from low- and middle-income countries show that trust is critical to motivate healthcare workers.

In the context of healthcare workers, trust is their belief that the health system will enable them to offer their patients appropriate care. It should also provide an environment in which they can fulfil their professional responsibilities without coming to any harm – personally or professionally.

Research shows that healthcare workers’ trust in the health system is built on expectations being met in relation to a number of factors. These include:

  • working conditions (such as safety and security, working hours, workload),

  • human resources practices (such as salaries, training opportunities, mentoring and counselling), and

  • inclusive organisational culture and supportive interpersonal factors (such as respect, recognition, supportive management and feedback).

The importance of these factors in building trust and motivation are even more critical in settings such as South Africa, where highly infectious diseases such as TB impose even greater occupational risks for healthcare workers.

As part of my research, I looked at community health workers at primary care facilities providing TB services in high-disease burden communities. These workers are a microcosm of healthcare workers across South Africa.

In my study several of these issues came up. For example, the community care workers raised working hours as a challenge. They complained of having to visit patients in the evenings and on weekends, often outside formal working hours.

They also complained that meetings were held outside working hours, clashing with their personal and domestic responsibilities. Inadequate pay was also mentioned a great deal. One community care worker explained:

I must go out and look for people in their houses. The money we are getting is little while the working we are doing (so) much. You are working for a pair of shoes that you use to walk the entire location.

This shows that healthcare workers’ trust in the health system is undermined by a combination of difficult working conditions. These include a government that continuously fails to meet their financial expectations and also fails to recognise opportunities for their professional growth.

Restoring trust

To restore healthcare workers’ trust, the National Health Department needs to implement human resources policies that demonstrate recognition and acknowledgement.

In addition, government must build an enabling and caring work environment for all healthcare workers. The World Health Organisation provides guidance on how this can be done, setting out how countries can support and strengthen healthcare worker motivation, satisfaction, retention and performance.

The government must also provide healthcare workers with psycho-social support. Examples include employee wellness programmes which include counselling and psychological services.

It must also provide a supportive work environment in which healthcare workers feel respected, empowered and safe to share their concerns.

And lastly, practises that support healthcare workers being respected by patients and the community should be pursued. This can strengthen mutual trust between communities and healthcare workers and has the potential to improve motivation and patient care.

It’s time that South Africa built a health system that demonstrates care and restores trust for both patients and workers. Healthcare workers are the life-blood of people-centred health systems. That means that if policies fail to deliver for them, we all lose.