Abstract
BACKGROUND: Lack of trust in healthcare systems results in underutilization, non-adherence to medications, poor healthcare outcomes, and catastrophic health expenditure. Literature on people's trust on public health care system is limited in India. This study aims to examine the people's trust in public healthcare system in Bihar and explore the factors influencing it. METHODS: We conducted the study employing a sequential explanatory design. A door-to-door survey of 360 adults (mean age 45 years, men 65%) selected through multi-stage random sampling from two districts of Bihar was conducted employing "public healthcare system trust scale". It was followed up with 16 in-depth interviews of purposively selected respondents with a low-level of trust. Survey data were analyzed using binary logistic regression analysis and adjusted odds ratios (AOR) were computed. Qualitative interviews were analyzed employing thematic analysis. RESULTS: Majority of the participants (76.1%; 95% CI = 71.5-80.3) had low level of trust in public healthcare system, and 27.2% (CI = 22.8-32.0) preferred public healthcare service providers. Younger age of up to 45 years (AOR = 5.68, 95% CI = 2.61-12.37, p < 0.001), residing in East Champaran district (AOR = 7.61, 95%CI = 3.67-15.77, p < 0.001), and suffering from chronic disease (AOR = 2.47, 95% CI = 1.09-5.61, p = 0.037) were significantly more likely to report a low-level of trust in public healthcare system. Thematic analysis yielded six themes namely i) inadequacy of health services, ii) poor quality of services, iii) poor health systems process and management, iv) lack of trust building dialogue, v) previous negative experiences with public facilities and, vi) corona virus disease (COVID)-19 eroding trust on healthcare system. CONCLUSION: People's trust on public healthcare system in Bihar is low. Public health care system in the state needs to improve focusing on adequacy, quality, health system process and management and trust building dialogue.