• Authors: Joaninha D G Correia, Paulo Ferrinho, Luís Andrade
• Publication Year: 2021
• Journal: The International Journal of Health Planning and Management, 36(4), pp 1362–1365
• Link: https://doi.org/10.1002/hpm.3168

LETTER TO THE EDITOR

The Republic of Guinea-Bissau (RGB) is a former Portuguese colony with a 2021 population estimated at 2,015,494 (https://worldpopulationreview.com/countries/guinea-bissau-population).

Since the 1980s, it has experienced situations of political and institutional instability, reflected in repeated coups d’état, armed conflicts requiring the intervention of foreign peace-keeping forces, unconstitutional governance, workers’ strikes and failure to sustain the salaries of public servants, widespread corruption, persistent poverty and increased economic inequality. The dependence of the international community on the sectors of the economy, education and health is almost total.¹ According to the 2020 Fragile State Index, the RGB is the 19th most fragile state in the world and the 13th in Sub-Saharan Africa (SSA) (https://fragilestatesindex.org/country-data/). The 2020 Corruption Perception Index ranks the RGB as the 13th most corrupt country in the world and the 6th in SSA (https://en.wikipedia.org/wiki/Corruption_Perceptions_Index#2012%E2%80%932020).

In this letter, we report on the level of trust in public and private sector institutions in the RGB, including health care institutions. Data were collected in a cross-sectional analytical study from RGB citizens, between 25 and 59 years of age, working for different financial and banking (n = 12) or other public (n = 46, related to the ministries of education, health, foreign affairs and finance) or private [for profit (n = 33) and not for profit (n = 21)] institutions in the country’s capital city, Bissau, who had completed secondary education. In each institution data were collected by snowballing, starting with a known informer that distributed it among colleagues meeting the inclusion criteria until the institutional quota of questionnaires was completed. Data were collected from December 2019 to March 2020, using the close-ended questionnaire of the Institutional Trust Scale developed and validated by Finura.² The questionnaire collects data on level of education, sex, age, institutional function (administrative staff or midlevel technician; technician with university training; supervisor of one or more workers; leadership function of one or more supervisors), self-rated health (from very bad to very good in five categories), self-rated happiness (from never to all the time in five categories), as well as on the level of trust on 33 institutions, on a scale of 1–5 (where 1 is not trustworthy at all and 5 totally trustworthy). The question was formulated as follows: ‘defining the citizen’s trust in an institution as the expectation, belief or security, that he or she has that this institution fulfils its function with correctness and competence in relation to the citizen, please mark your confidence level with X in relation to the following institutions in your country’. All respondents had to respond in relation to all 33 institutions listed in the questionnaire. Collected data were entered into SPSS and analysed using descriptive statistics (mean, standard deviation and percentages).⁴

Of the 112 valid respondents, 51 were males (46%) and 59 females (54%) (no data on 2). Eighteen (16%), 66 (59%), 21 (19%) and 7 (6%) were aged 25–29, 30–39, 40–49 and 50–59 years, respectively. Sixty-six (59%) had higher education. Forty-nine (44%) had leadership or supervisory functions.

Health was self-rated as reasonable (n = 15, 13%), bad (n = 47, 42%) or very bad (n = 50, 45%). No one reported good or very good health.

Feeling happy was something that never happened (n = 51, 45%), happened rarely (n = 58, 52%) or only sometimes (n = 3, 3%).

Private health services and physicians rank high in the first 10 most trustworthy institutions. Public health services rank below 3 in the 1 to 5 scale in 19th position. In general, state and government institutions rank poorly.

In the RGB’s context of fragility and corruption, it should be expected, as observed in this study, that the trust of citizens in their institutions would be compromised. Research has also shown that people with poorer self-rated health, as observed for this study, have lower levels of trust.³ As ‘trust is regarded as a necessary component for the smooth running of society and the glue that holds society together’ and ‘the act of trusting reduces complexity in society, allowing individuals to get on with other aspects in their lives’, developing policies to increase trust within societies should be a concern of policymakers.⁵

The existing evidence is that discontent with health system performance is widespread in low- and high-income countries alike.^6, 7 This is likely to be associated with reduced access to health care and compromised health status.³ This may also partially explain why efforts to strengthen district level planning in poorer countries, using technical approaches for priority setting, based on burden of disease measures, cost effectiveness analysis or capacity considerations have not achieved proposed sustainable developments. These technical approaches fail to consider the full range of, and may actually place in confrontation, relevant values such as efficiency and equity, identifying the need for a complementary focus on other relevant values, such as trust in healthcare systems.^8–14 In the context of the SDG agenda, and the resulting need for new approaches for strengthening planning for sustainable health,¹⁵ strategic frameworks need to consider measures of trust in the health system and address the means to improve that trust.

KEYWORDS

Guinea-Bissau; health institutions; health care; public; private; trust.