Truth, humane treatment, and identity: perspectives on the legitimacy of the public and private health sectors during Covid in Zambia

Legitimacy is necessary for resilience and trust helps to legitimize health systems. Providing services during Covid has relied on both the private and public sectors but there is little information on differences in trust between these sectors during shocks like Covid and how it may impact the health system’s legitimacy. The purpose of this study was to explore community trust in the public and private sectors of the Zambian health system during Covid, to generate understanding on how trust in the different sectors may influence the system’s legitimacy. Twelve focus groups discussions and 22 key informant interviews were conducted in 2022 with community members who used public, private, and faith-based services during Covid and service providers, and thematic analysis identified perceptions of trust between the different sectors. The themes ‘Humane, patient-centred treatment’ and ‘Communicating the truth’ describe the desire for humane interactions and truthfulness during Covid, compromised by fear, uncertainty, and suspicions of the motives of the sectors, and alleviated by support, security, and shared identity. The legitimacy of the public sector was influenced by shared spaces, values, and identities with communities. The private sector maintained its legitimacy through service quality and its identity as a non-governmental business. Interpersonal trust was important, but identity played a larger role than high-quality interactions for legitimacy in Zambia during the pandemic. To enhance legitimacy and resilience during shocks, potential strategies include strengthening the quality of public sector interactions to meet private sector standards, emphasizing the public sector as a public good, and clarifying the public sector’s role vis-à-vis the government during crises.