Managing uncertainty in medicine quality in Ghana: The cognitive and affective basis of trust in a high-risk, low-regulation context

Abstract

Where regulation is weak, medicine transactions can be characterised by uncertainty over the drug quality and efficacy, with buyers shouldering the greater burden of risk in exchanges that are typically asymmetric. Drawing on in-depth interviews (N = 220) and observations of medicine transactions, plus interviews with regulators (N = 20), we explore how people in Ghana negotiate this uncertainty and come to trust a medicine enough to purchase or ingest it. We identify two mechanisms – attempts to mitigate uncertainty through seeking observable signs of quality and attempts to reduce informational asymmetry – that underpin cognitive assessments of a medicine's trustworthiness. However, these ‘cognitive’ forms of trust assessment have limited traction where uncertainty is high and trustworthiness remains unknowable, so a third mechanism comes into play: one based on affective relationships within which transactions are socially embedded. Even these, however, cannot eliminate uncertainty, because of the dispersed and under-regulated nature of wider supply chains. In conclusion, we reflect on the need for careful research on actors' practices and decision-making across supply chains to inform more effective policy and regulation.

Trust, community health workers and delivery of intermittent preventive treatment of malaria in pregnancy: a comparative qualitative analysis of four sub-Saharan countries

“…This sense of relatedness (Druetz et al, 2015) can contribute to breaking up the possible reluctances to C-IPTp uptake. This is in agreement with multiple studies (Druetz et al, 2015;Kane et al, 2016;Kok et al, 2017;Tine et al, 2013), including a recent study on access to quality medicines in Ghana, which claimed that 'where trust is socially embedded, buyers are inclined to give the retailer the benefit of doubt, even when presented with possible evidence to the contrary' (Hamill et al, 2019).…”

“…However, having a common residence or a common sociocultural background does not necessarily mean a direct correlation with acceptance of CHWs' activities. Thus, whilst it is widely recognised that the bonds of kinship, friendship or other social structures may have a positive effect in patient-provider relationships, affective relationships cannot erase mistrust in the formal system, but can rather 'make uncertainty more manageable' (Hamill et al, 2019). This can also be applied to the findings in our study, where the facilitating role of CHWs with regard to C-IPTp is not always perceived to be sufficient to guarantee its success.…”

Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries?

“…HCP commitment and ability to respond to the health needs of the communities they serve and to act in patients' best interest is critical for numerous reasons. It has a major impact on the quality and cost of care that patients receive during transactions characterised by uncertainty, informational asymmetry, and buyer vulnerability [12]. Beyond impacts on individuals, the education and role of HCPs affect global health security owing to the increasing cross-national transfer of health expertise, health services, and infectious diseases [13,14].…”

Comparative Quality Evaluation of Selected Brands of Cefuroxime Axetil Tablets Marketed in the Greater Accra Region of Ghana

“…Hence, the need to tackle SF drugs holistically is urgent and critical [ 9 ]. Relatedly, another emerging risk as reported by recent studies is the lack of confidence and breached trust among SF drug users (with unmet therapeutic goals) toward legitimate drug use, the entire health system, and qualified healthcare professionals as well as some credible manufacturing industries [ 8 , 10 , 11 ]. This mistrust has refueled another emerging public health danger of self-diagnosing, self-prescribing, and misuse of drugs accessed from unethical open access global markets (e-commerce), thus complicating the already vicious cycle created [ 9 , 12 ].…”

“…Hence, the need to tackle SF drugs holistically is urgent and critical [9]. Relatedly, another emerging risk as reported by recent studies is the lack of confidence and breached trust among SF drug users (with unmet therapeutic goals) toward legitimate drug use, the entire health system, and qualified healthcare professionals as well as some credible manufacturing industries [8,10,11].…”