Building trust in Kenyan rural public health facilities.

Author:Miruka, Collins Ogutu


Most Kenyans seem to have lost trust in government institutions as impartial public service providers. For instance, many of them would be astonished to learn that one has obtained a passport or a driver's license without 'knowing someone' or 'paying something small.' However, despite this being the perception of the majority of the people, it is not always the case. There are numerous examples of exemplary public servants as well as institutions. This paper is concerned with this issue of lack of trust in public institutions and uses Kenyan rural health facilities as a case study. The purpose of this paper is to explore factors that engender this practice and thus erode the requisite stocks of social capital that is required for good governance to take root at these facilities. A field study was undertaken in western Kenya where four institutions were used as research sites. A questionnaire was administered to both the community of health service providers and users to determine the level of trust that exists in these institutions, and how they impact on service delivery. The study found that ethnicity, amongst other prejudices, was a major hindrance to the realization of quality health care service delivery in these facilities.

Purpose of the Research

On-going research trends correlate social capital in the form of social trust and associational networks, with a multiplicity of desirable policy outcomes such as low crime rates, lower transactional costs and less corrupt and more effective government. The purpose of this research is to observe closely, at macro and micro levels, the manifestations of social capital amongst service providers and community of users at selected rural health facilities. This kind of observation provides a detailed description of what transpires at the inter-phase of service delivery when the existing social capital amongst the community of users interacts with the norms and attitudes of public servants charged with service delivery.

Research Objectives

The study was largely motivated by evidence in the literature dealing with social capital that suggests that the concept has large untapped economic payoffs. For example, Fukuyama (1999) cites the success of the Japanese Economic Planning Ministry (MITI) in delivering credit allocation over the years to particular industries, which was deemed vital to the overall performance of the Japanese economy. Fukuyama attributes this success to the prevalence of a unique form of social capital amongst the Japanese bureaucrats and citizens.

The notion of social capital is especially pertinent to service delivery in the social sectors, such as the health sector, where the ordinary rules of perfectly competitive markets do not apply. The relationship between the doctor and patient is not quite similar to that between, for example, those exchanging vegetables or a house for money.

It is generally assumed, and it is quite possible, that the majority of the buyers of the latter are rational and familiar with the items they are purchasing and are thus better able to discriminate while conducting the purchase. In as much as an ordinary patient may be engaged in exchange of his money for medical services, he/she, however, would not have as much knowledge as the licensed service provider, whether nurse, doctor or pharmacist, about the medicine. The latter categories of consumers are relatively less able to discriminate.

Because of the existing information asymmetry in the market for healthcare services, patients are forced by circumstances to depend more on trust. Thus, they are left to 'trust' that the professional will offer quality service to them. In the absence of this trust, clients would only be prepared to pay for the services at the value of the poorest quality of service available. The concern here is about the perceived bottlenecks amongst the community of service users as well as service providers to effective public service delivery that are pertinent to the concept of social capital.

In this study, the concept of social capital is depicted as a unit of analysis in an attempt to explore the failures of rural health facilities regarding service delivery. The debate on social capital (see, for instance, Grootaert and van Baastelar, 2002; Isham, Kelly and Ramaswany, 2002) presents an exciting new paradigm in development theory. The norms that constitute social capital generally range from friendship reciprocities all the way to the more complex norms that bind together huge organizations such as trade unions and churches (Fukuyama, 1999). Put simply, social capital refers to the informal and unwritten understandings that enable members of society to relate to each other in mutually beneficial ways.

In the pursuit of individual goals, society members are, in line with the positive tenets of social capital, expected to be mindful of other people's welfare. Henceforth, norms of reciprocations and obligations are created that are ideally self-perpetuating. I am of course referring here to 'positive' social capital to distinguish the phenomenon from the type of associations that are formed by cartels, criminal gangs, and ethnic groupings against outsiders.

Research Questions

In many rural areas of Kenya, the quality of health care facilities and service delivery systems has been less than satisfactory. Over the years, several attempts have been made to reform these services to improve on delivery. Mostly, the emphasis has been on enhancing health infrastructure and logistics, remuneration and capacity building of the employees. These endeavours have yielded mixed results, to say the least.

The core assumption of this research is that the concept of social capital influences to a great degree the quality of public provisioning in Kenya. It delimits the agency of the current public service reform drivers as characterized by the good governance discourse. To ascertain the impact of social capital on these management practices and ethos of those managing rural health facilities, the research seeks to address the following questions:

* How does the concept of social capital impact on health care service delivery?

* What erodes trust in rural health facilities?

* How do the associational norms of both the community of users as well as the service providers affect health care service delivery?

Research Design

This study employs both a survey and qualitative research methods in order to understand and describe how the phenomenon of social capital manifests itself in institutional settings. This is achieved by the use of in-depth interviews, focus group discussions as well as a questionnaire to arrive at understandings and interpretations of how service providers and community of users at rural health facilities build and exploit social capital as they interact. This is because, as Leedy and Ormrod (2001) demonstrate, the gathering of accurate information about the phenomena being investigated is crucial given that this is an interpretive study.

The institutions chosen for this study are severely resource-constrained and many people who patronize them do so for lack of a better alternative. In Kenya, it is generally conceived that only those who lack the means to access private health care opt for rural health facilities (ee, Kimelu et al., 2004). Nevertheless, as the majority of Kenyans are poor, they have no alternative but to visit these much-maligned centres. Since the overriding complaint of staff in these institutions is overwork, relatives of in-patients in many instances take it upon themselves to feed, wash and change the patients.

In-Depth Interviews

Purposive sampling was used to select information-rich cases for in-depth study. This type of sampling involves selection of sites and informants based on important characteristics under study. In the course of this study, the researcher carried out fourteen in-depth interviews with various medical personnel and hospital administrators.

The researcher also carried out seven focus-group interviews over the same period. The hospitals were largely chosen for ease of access and convenience. The hospitals used in this survey included Pap-Onditi Health Centre in Nyando District, St Joseph's Nyabondo Mission Hospital, Rachuonyo District Hospital, and Oboch Rural Health facility in Nyando District.

The researcher chose as key informants mostly the medics who also served as...

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